Prior authorization forms

Download and print the most commonly requested prior authorization fax forms for commercial and FEP procedures, injectable drugs (office administered and home self-administered) and oral/topical drugs, choosing from the lists below. You need Adobe Reader to view the forms.

Blue Shield 65 Plus forms

Prior Authorization/Coverage Determination Form (PDF, 136 KB)

Non-Formulary Exception and Quantity Limit Exception (PDF, 129 KB)

Tier Exception (PDF, 109 KB)

Prescription drug prior authorization and step therapy exception request forms

Office drugs prior authorization request (PDF, 301 KB)

Home Self-Administered Injectable Drug authorization request (PDF, 288 KB)

Oral/Topical Drugs (PDF, 288 KB)

Procedure authorization request forms