Prior authorization forms and templates

Download and print the most commonly requested prior authorization fax forms for procedures, physician administered drugs and pharmacy outpatient drugs, choosing from the lists below.

Please be certain to choose the template that applies to the patient’s benefit plan. Below you will find forms for:

• Blue Shield of California Medicare Advantage plans
• Blue Shield of California Promise Health Plan (for Medi-Cal members)
• Procedure authorization request forms for radiation oncology, advanced imaging, spine surgery and pain management services
• Blue Shield of California commercial HMO and PPO plans
• Additional procedure authorization request forms for commerical plan members: Procedures/HCPCS
• Procedures for Federal Employee Program members

Blue Shield of California Medicare Advantage plans

About Part B Medication Authorization 

For Blue Shield Group Medicare Advantage (PPO) plan members, medical services and Part B medications may be subject to prior authorization. To submit those requests, please visit the Evolent website.

Medicare Part D coverage determination form (PDF, 306 KB)

Medicare Part D formulary and quantity limit exception form (PDF, 277 KB)

Medicare Part D tier exception form (PDF, 177 KB)

Medicare medical service prior authorization form (PDF, 187 KB)

Medicare medical service urgent expedited prior authorization form (PDF, 131 KB)

Medicare medical service transplant prior authorization form (PDF, 312 KB)

Medicare Part B physician administered medication prior authorization form (PDF, 503 KB)

Blue Shield of California Promise Health Plan

Find authorization and referral forms

Blue Shield of California commercial HMO and PPO plans

Prescription drug prior authorization and step therapy exception request forms for commercial plan members

Continuous glucose monitoring authorization request form (PDF, 177 KB)

Healthcare professional/physician — administered drug requests (medical benefit drugs) (PDF, 301 KB)

Pharmacy outpatient drug requests (pharmacy benefit drugs) (PDF, 288 KB)

Servicing provider change request form for medical benefit medications (PDF, 98 KB)

Procedure authorization request forms for radiation oncology, advanced imaging, spine surgery and pain management services

To submit prior authorization requests for radiation oncology services in an outpatient or office setting, for commercial PPO, Group Medicare Advantage PPO, and Trio HMO plan members, please visit the Evolent website and select "CarePro".

To submit prior authorization requests for advanced imaging, spine surgery, and pain management for commercial plan and Group Medicare Advantage PPO members, please visit the Evolent website and select “RadMD”.

Additional procedure authorization request forms for commercial plan members: Procedures/HCPCS