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.

Medicare Part D prior authorization forms
Coverage Determination Request Form
Coverage Determination Request Form - Injectable Drug
Acthar
Adempas
Afinitor
Alecensa
Aranesp
Benlysta
Berinert
Bethkis
Bosulif
Braftovi
Cerdelga
Cerezyme
Cinryze
Compound Drug
Dronabinol
Drugs to Avoid in the Elderly - High Risk Medications
Egrifta
Enbrel
Epclusa
Erivedge
Esbriet
Estrogen - High Risk Medication
Fentanyl, transdermal
Gattex
Gilotrif
Haegarda
Harvoni
Hetlioz
Hizentra
Hospice Unrelated Drugs
Humira
IVIG
Ibrance
Imbruvica
Iressa
Itraconazole
Jakafi
Juxtapid
Kadcyla
Keytruda
Kisqali
Letairis
Leukine
Lynparza
Mavyret
Mekinist
Mektovi
NarcoticER
Neulasta
Neupogen
Nexavar
Ninlaro
Non-Formulary Exception Request
Norditropin
Noxafil
Ofev
Opdivo
Opsumit
Praluent
Procrit
Prolia
Promacta
Quantity Limit Exception
Regranex
Relistor
Remicade
Repatha
SCIG
Serostim
Sporanox Oral Solution
Sprycel
Stivarga
Sutent
TOBI
Tafinlar
Tarceva
Tavalisse
Tier Exception
Total Parental Nutrition
Tracleer
Tykerb
Tymlos
Uptravi
Vaccine
Venclexta
Vosevi
Votrient
Xgeva
Xifaxan
Xolair
Zejula
Zelboraf
Zortress - BvD
alosetron
aprepitant
armodafinil
azathioprine - BvD
cyclosporine - BvD
dalfampridine (Ampyra)
eszopiclone
glyburide - High Risk Medication
granisetron
ibandronate IV
levalbuterol solution
linezolid
miglustat
modafinil
mycophenolate - BvD
nebulizer solutions - BvD
nitrofurantoin - High Risk Medication
ondansetron - BvD
oxycodone er (Oxycontin)
sildenafil (Revatio)
sirolimus (Rapamune) - BvD
tacrolimus - BvD
tadalafil (Adcirca)
tobramycin nebulized
voriconazole
zaleplon
zolpidem_zolpidem er

 

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.

For more information about prior authorizations, check out Frequently asked questions and our Medicare Part D user guide.