Some drugs in the formulary require you or your prescriber to get prior authorization. This means that you will need to get approval from us before you fill your prescriptions. If you don't get an approval, Blue Shield may not cover the drug.
How to request a prior authorization?
To request a prior authorization for a drug, you, your doctor, other prescriber or appointed representative need to contact Blue Shield and provide clinical information. If the necessary information is not submitted or the information does not meet the prior authorization criteria, the drug may not be covered. Read more about what clinical information may be required below.
Prior authorization for a prescription medication may be requested over the phone or via fax using an appropriate form listed below. Your doctor's office phone or fax number must be provided with a request.
Phone: (800) 535-9481 (TTY 711), Monday through Friday from 8 a.m.- 6 p.m. PST
Fax: (888) 697-8122
Find a prior authorization request form in the list below - click on the drug name to download the fax form. If your drug is not listed, use the general coverage determination form listed at the top of the index.
Medicare Part D prior authorization forms index
By clicking on a listed drug name, you can access the fax form that may be used to request prior authorization to cover a drug. If your drug is not listed, use the general coverage determination form listed at the top of the index.
Clinical information guidelines
For a prior authorization request to be considered for approval, a doctor must provide clinical information which may include, but is not limited to the following:
- The diagnosis or reason(s) you are being treated with the drug, or
- Lab test information (for example, LDL level for cholesterol treatment or the hemoglobin A1c level for diabetes treatment), or
- Your doctor's specialty or whether you have been evaluated by a specialist, or
- What other treatment(s) has been attempted and whether they were effective or if you experienced side effect from them, or
- What dose is required and how long is your expected treatment, or
- Is a generic drug alternative medically appropriate for you.
In addition, if a formulary or tiering exception is requested, your doctor must provide a statement supporting your request.