Download and print the most commonly requested prior authorization fax forms for procedures, injectable drugs (office administered and home self-administered) and oral/topical drugs, choosing from the lists below..
Blue Shield of California Promise Health Plan, Medi-Cal and Cal MediConnect
Find authorization and referral forms
Blue Shield Medicare
Non-Formulary Exception and Quantity Limit Exception (PDF, 129 KB)
Prior Authorization/Coverage Determination Form (PDF, 136 KB)
Prior Authorization Generic Fax Form (PDF, 173 KB)
Prior Authorization Urgent Expedited Fax Form (PDF, 126 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
- Actigraphy
- Advanced Imaging
- Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
- Auditory Brainstem Implant
- Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
- Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
- Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis
- Bariatric Surgery
- Bioengineered Skin and Soft Tissue Substitutes
- 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)
- Breast Implant Management
- Cellular Immunotherapy for Prostate Cancer
- Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
- Clinical Trial (for any indication)
- Computed Tomography to Detect Coronary Artery Calcification
- Continuous Glucose Monitoring
- Continuous Passive Motion in the Home Setting
- Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
- Dental Anesthesia
- Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
- Elective Invasive Coronary Angiography (ICA)
- Elective Percutaneous Coronary Intervention (PCI)
- Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
- Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
- Esophageal pH Monitoring
- External Insulin Infusion Pump
- Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
- Extracranial Carotid Artery Stenting
- Functional Neuromuscular Electrical Stimulation
- Gender Reassignment Surgery
- General Request
- Genetic Testing for Cardiac Ion Channelopathies
- Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies
- Genetic Testing for Diagnosis and Management of Mental Health Conditions
- Genetic Testing for Inherited Thrombophilia
- Genetic Testing for Mitochondrial Disorders
- Home Health Care
- Hyperbaric Oxygen Therapy
- Hysterectomy Surgery for Benign Conditions
- Implantable Cardioverter Defibrillator
- Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
- Intensity Modulated Radiation Therapy (Generic IMRT)
- Intensity-Modulated Radiotherapy of the Breast and Lung
- Intensity-Modulated Radiotherapy of the Prostate
- Intensity-Modulated Radiotherapy: Abdomen and Pelvis
- Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
- Intensity-Modulated Radiotherapy: Central Nervous System Tumors
- Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
- Intraoperative Radiotherapy
- Knee Arthroscopy
- Knee Arthroscopy in Knee Osteoarthritis
- Knee Braces (Custom)
- Lumbar Spine Surgery
- Magnetic Resonance Spectroscopy
- Magnetoencephalography/Magnetic Source Imaging
- Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
- Microprocessor Controlled Lower Limb Prostheses
- Microwave and Locoregional Laser Tumor Ablation
- Myoelectric Prosthetic and Orthotic Components for the Upper Limb
- Negative Pressure Wound Therapy in the Outpatient Setting
- Neuropsychological Testing
- Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
- Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
- Nonpharmacologic Treatment of Rosacea
- Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
- Orthognathic Surgery
- Orthopedic Applications of Platelet-Rich Plasma
- 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
- Pneumatic Compression Pumps for Treatment of Lymphedema and Venus Ulcers
- Power Wheelchairs and Power Operated Vehicles for Permanent Use
- Radiation Oncology
- Radioembolization for Primary and Metastatic Tumors of the Liver
- Radiofrequency Ablation of Primary or Metastatic Liver Tumors
- Reconstructive Services
- Reduction Mammaplasty
- Reproductive Techniques
- Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
- Spine and Pain Management
- Subtalar Arthroereisis
- Surgical Deactivation of Headache Trigger Sites
- Surgical Treatment of Femoroacetabular Impingement
- 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 Hyperhidrosis
- Treatment of Varicose Veins Venous Insufficiency
- Urgent Expedited Request
- Wearable Cardioverter Defibrillators
- Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
- Whole Gland Cryoablation of Prostate Cancer
- Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
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