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

Commercial procedures / HCPCS
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer
Actigraphy
Advanced Imaging
Auditory Brainstem Implant
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis
Bariatric Surgery
Beta-Amyloid Imaging with Positron Emission Tomography for Alzheimer Disease
Biofeedback as a Treatment of Urinary Incontinence in Adults
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
Breast Implant Management
Cardiac Applications of Positron Emission Tomography Scanning
Catheter Ablation for Cardiac Arrhythmias
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Clinical Trial (for any indication)
Cochlear Implant
Computed Tomography Perfusion Imaging of the Brain
Computed Tomography to Detect Coronary Artery Calcification
Continuous Passive Motion in the Home Setting
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
Contrast-Enhanced Coronary Computed Tomography Angiography for Coronary Artery Evaluation
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
Dental Anesthesia
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Elective Percutaneous Coronary Intervention (PCI)
Endobronchial Brachytherapy
External Insulin Infusion Pump
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
Functional Neuromuscular Electrical Stimulation
Gender Reassignment Surgery
General Request
Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers
Genetic Testing for Inherited Thrombophilia
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Genetic Testing for Mitochondrial Disorders
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
High-Dose Rate Temporary Prostate Brachytherapy
Home Health Care
Hyperbaric Oxygen Therapy
Hysterectomy Surgery for Benign Conditions
Implantable Bone-Conduction and Bone-Anchored Hearing Aids
Implantable Cardioverter Defibrillator
Implantation of Intrastromal Corneal Ring Segments
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Intensity Modulated Radiation Therapy (Generic IMRT)
Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
Knee Arthroplasty for Adults
Knee Arthroscopy
Knee Braces
Lower Limb Prostheses
Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer
Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants
Magnetic Resonance Spectroscopy
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
Microprocessor Controlled Lower Limb Prostheses
Microwave and Locoregional Laser Tumor Ablation
Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorodeoxyglucose F 18 Positron Emission Tomography
Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Negative Pressure Wound Therapy in the Outpatient Setting
Neuropsychological Testing
Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
Nonpharmacologic Treatment of Rosacea
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Oncologic Applications of Positron Emission Tomography Scanning
Orthognathic Surgery
Orthopedic Applications of Platelet-Rich Plasma
Orthoptic Training for the Treatment of Vision or Learning Disabilities
Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti
Partial Thickness Rotator Cuff Tears and Acromioplasty Subacromial Decompression
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Physical Therapy- Applies to eBay only
Positron Emission Mammography
Power Wheelchairs and Power Operated Vehicles for Permanent Use
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Reconstructive Services
Reduction Mammaplasty for Breast-Related Symptoms
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Spine and Pain Management
Subtalar Arthroereisis
Surgical Deactivation of Headache Trigger Sites
Surgical Treatment of Gynecomastia
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Total Artificial Hearts and Implantable Ventricular Assist Devices
Total Hip Arthroplasty for Adults
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Treatment of Varicose Veins Venous Insufficiency
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Urgent Expedited Request
Virtual Colonoscopy/Computed Tomography Colonography
Wearable Cardioverter Defibrillators
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
Whole Gland Cryoablation of Prostate Cancer
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
Procedures for Federal Employee Program members
ABA Therapy
Actemra
Actimmune
Adcetris
Adcirca
Adempas
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
Afinitor
Afrezza
Aldurazyme
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Artificial Intervertebral Disc-Cervical Spine
Artificial Intervertebral Disc-Lumbar Spine
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions
Automated Percutaneous and Endoscopic Discectomy
Avastin
Axial Lumbosacral Interbody Fusion
Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis
Bariatric Surgery
Bio-Engineered Skin And Soft Tissue Substitutes
Biofeedback
Biventricular Pacemakers for the Treatment of Heart Failure
Blepharoplasty, Blepharoptosis Repair, and Brow Lift
Bone Mineral Density Studies
Bone Morphogenetic Protein
Botox
Brachytherapy for Clinically Localized Prostate Cancer
Brachytherapy for Oncologic Indications
Cardiac Applications of Positron Emission Scanning
Cardiovascular Risk Panels
Catheter Ablation for Cardiac Arrhythmias
Cervical Spinal Fusion
Chromoendoscopy as an Adjunct to Colonoscopy
Cleft Palate Dental Related Services
Clinical Trial (for any indication)
Cochlear and Auditory Brainstem Implants
Cognitive Rehabilitation
Congenital Anomalies
Cranial Electrotherapy Stimulation
Cryosurgical Ablation of Miscellaneous Solid Tumors
Deep Brain Stimulation
Dermatologic Applications of Photodynamic Therapy
Detection of Circulating Tumor Cells
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Diagnosis and Treatment of Sacroiliac Joint Pain
Discectomy
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography
Electrical Bone Growth Stimulation
Emend
Endoscopic Injection
Endoscopic Radiofrequency Ablation
Enhanced External Counterpulsation
Entyvio
Epidural Steroid Injections for Back Pain
Epogen Procrit
Extension of Benefits
External Insulin Infusion Pump
Facet Arthroplasty
Facet Joint Denervation
Facet Joint Injections and Facet Joint Nerve Blocks
Functional Neuromuscular Electrical Stimulation
Gastrointestinal Motility and Manometry Testing
Gender Reassignment Surgery
Gene Expression Profiling for Managing Breast Cancer Treatment
General Anesthesia for Dental Procedures
General Request
Genetic Testing for Cadasil Syndrome
Genetic Testing for Colorectal Cancer
Genetic Testing for Hereditary Breast and/or Ovarian Cancer
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Hospice
Hyaluronic Acid Agents
Hyperbaric Oxygen Therapy
IMRT Abdomen and Pelvis
IMRT Breast and Lung
IMRT Central Nervous
IMRT Generic
IMRT Head and Neck or Thyroid
IVIG Immune Globulin
Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis
Immune Cell Function Assay
Implantable Cardioverter Defibrillator
Implantable Middle Ear and Bone-Anchored Hearing Aids
Implantation of Intrastromal Corneal Ring Segments
Incontinence Treatment System
Ingestible pH and Pressure Capsule
Injectable Bulking Agent
Inpatient Residential Treatment
Intraoperative Radiotherapy
KRAS, NRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer
Knee Braces
Laminectomy
Lower Limb Prostheses
Lumbar Spinal Fusion
Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer
Manipulation Under Anesthesia
Medical Injectable Drug
Microprocessor-Controlled Prostheses for the Lower Limb
Miscellaneous Applications of PET
Monitored Anesthesia Care
Negative Pressure Wound Therapy in the outpatient setting
Neuromuscular and Functional Electrical Stimulation
Neuropsychological Testing
Oncologic Applications of PET Scanning
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures)
Oral Maxillofacial Procedures
Orthognathic Surgery
Orthopedic Applications of Platelet-Rich Plasma
Orthoptic Training for the Treatment of Vision or Learning Disabilities
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Diseases
Panniculectomy, Abdominoplasty and Surgical Management of Diastasis Recti
Percutaneous Vertebroplasty and Sacroplasty
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
Positron Emission Tomography (PET)
Power Wheelchair
Prolia
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Solid Tumors Excluding Liver Tumors
Reduction Mammaplasty for Breast-Related Symptoms
Regional Sympathetic Blocks
Remicade
Rituxan
Sacroiliac Joint Injections
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Sinuva
Skilled Nursing Facility (standard option plan ONLY)
Spinal Cord Stimulation
Surgical Treatment of Bilateral Gynecomastia
Surgical Treatment of Morbid Obesity (Benefit)
Temporomandibular Joint Dysfunction
Transcranial Magnetic Stimulation
Transurethral Radiofrequency
Treatment of Varicose Veins Venous Insufficiency
UVPP UPPP
Urgent Request for Prior Authorization
Virtual Colonoscopy Computed Tomography Colonography
Wearable Cardioverter Defibrillator
Wireless Capsule Endoscopy
Xgeva