Prior authorization forms

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, 201 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