Prior authorization forms and templates

Download and print the most commonly requested prior authorization fax forms for procedures, physician administered drugs and pharmacy outpatient drugs, choosing from the lists below.

Please be certain to choose the template that applies to the patient’s benefit plan. Below you will find forms for:

• Blue Shield of California Medicare Advantage plans
• Blue Shield TotalDual (HMO D-SNP) plan
• Blue Shield of California Promise Health Plan (for Medi-Cal members)

Blue Shield of California Medicare

About Part B Medication Authorization 

For Blue Shield Group Medicare (PPO) plan members, medical services and Part B medications may be subject to prior authorization. To submit those requests, please visit the Evolent website.

Medicare Part D coverage determination form (PDF, 306 KB)

Medicare Part D formulary and quantity limit exception form (PDF, 277 KB)

Medicare Part D tier exception form (PDF, 204 KB)

Medicare medical service prior authorization form (PDF, 187 KB)

Medicare medical service urgent expedited prior authorization form (PDF, 131 KB)

Medicare Part B physician administered medication prior authorization form (PDF, 503 KB)

Blue Shield TotalDual (HMO D-SNP)

Templates for authorization-related notices​​

The templates and non-disclosure attachments, available below to download, are to be used as appropriate for notifying Blue Shield TotalDual (HMO D-SNP) or Blue Shield Inspire (HMO D-SNP) plan members regarding authorization determinations. All of these notices must be accompanied by the non-disclosure attachments, also available below to download, in the preferred language of the member.

Template for all carveout notice (PDF, 56 KB)

Template for all detailed explanation of non-coverage (updated) (PDF, 66 KB)

Template for all detailed notice of discharge (updated) (PDF, 67 KB)

Template for all expedited criteria do not meet (PDF, 64 KB)

Template for all notice of dismissal of coverage (updated) (PDF, 60 KB)

Template for all notice of Medicare non-coverage (PDF, 68 KB)

Template for all service approval (PDF, 68 KB)

Template for denial notice (PDF, 108 KB)

Template for DSNP CDLI denial (PDF, 119 KB)

Template for fast complaint letter (PDF, 105 KB)

Non-disclosure attachments to include with all notices sent to members​

You can download and use the non-disclosure attachment in the member’s preferred language, to include with any notice you send to the member. The notices are available in Arabic, Armenian, Chinese, English, Farsi, Hmong, Khmer, Korean, Spanish, Tagalog, and Vietnamese.​

Arabic non-disclosure attachment​ (PDF, 115 KB)

Armenian non-disclosure attachment​ (PDF, 78 KB)

Chinese (traditional) non-disclosure attachment​ (PDF, 95 KB)

English non-disclosure attachment​ (PDF, 597 KB)

Farsi non-disclosure attachment​ (PDF, 100 KB)

Hmong non-disclosure attachment​ (PDF, 58 KB)

Khmer non-disclosure attachment​ (PDF, 136 KB)

Korean non-disclosure attachment​ (PDF, 79 KB)

Spanish non-disclosure attachment​ (PDF, 79 KB)

Tagalog non-disclosure attachment​ (PDF, 40 KB)

Vietnamese non-disclosure attachment (PDF, 133 KB)

Blue Shield of California Promise Health Plan

Find authorization and referral forms

Prescription drug prior authorization and step therapy exception request forms for Commercial members

Continuous glucose monitoring authorization request form (PDF, 177 KB)

Healthcare professional/physician — administered drug requests (medical benefit drugs) (PDF, 301 KB)

Pharmacy outpatient drug requests (pharmacy benefit drugs) (PDF, 288 KB)

Servicing provider change request form for medical benefit medications (PDF, 98 KB)

Procedure authorization request forms

To submit prior authorization requests for radiation oncology services in an outpatient or office setting, please visit the Evolent website.