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Prior Authorization Forms

Download and print the most commonly requested prior authorization fax forms for commercial and FEP procedures, injectable drugs (office administered and home self-administered), and oral/topical drugs, choosing from the lists below.

You can also request authorization for Blue Shield 65 Plus by using the form below:

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Office Administered Drugs

File Name
Injectable Medication Coverage Request Form - CA mandate (SB866)
17-alphahydroxyprogesterone (17P)
Abatacept
Abilify Maintena
AbobotulinumtoxinA
Abraxane
Actemra
Acthar
Actimmune
Adalimumab
Adcetris
Ado-Trastuzumab emtansine
Aflibercept
Agalsidase beta
Aglucosidase alfa
Aldesleukin
Alemtuzumab (Campath)
Alemtuzumab (Lemtrada)
Alferon-N
Alglucerase
Alimta
Alirocumab
Aloxi
Anakinra
Anidulafungin
Anzemet
Aranesp
Arcalyst
Aripiprazole
Arixtra
Arzerra
Asparaginase
Avastin
Aveed
Avonex
Azacitidine
Belatacept
Beleodaq
Belinostat
Belimumab
Bendamustine
Benlysta
Berinert
Betaseron
Bevacizumab
Bivigam
Blincyto
Blinotumomab
Boniva
Bortezomib
Botox
Botulinum Toxin Type A
Botulinum Toxin Type B
Brentuximab
C1 Inhibitor (Berinert, Cinryze)
C1 Inhibitor ecallantide (Kalbitor)
C1 Inhibitor recombinant (Ruconest)
Cabazitaxel
Calcitonin Salmon
Campath
Canakinumab
Cancidas
Capsaicin 8% Patch
Carfilzomib
Carimune
Caspofungin
Cefotaxime
Ceftriaxone
Cerezyme
Certolizumab pegol
Cetuximab
Cimzia
Cinryze
Claforan
Clofarabine
Clolar
Collagenase
Copaxone
Corticotropin
Cosentyx
Cyramza
Cytogam
Dacogen
Dalbavancin
Dalteparin
Dalvance
Darbepoetin alfa
Decitabine
Denosumab (Prolia,Xgeva)
Desiriduin
Dexamethasone intravitreal implant
D.H.E. 45
Dihydroergotamine
Dolasetron
Dysport
Ecallantide
Eculizumab
Egrifta
Elaprase
Elelyso
Elosulfase alfa
Emend
Enbrel
Enoxaparin
Entyvio
Epoetin
Epogen
Epoprostenol
Eraxis
Erbitux
Eribulin
Erwinase
Erythropoietin
Etanercept
Euflexxa
Evolucumab
Extavia
Eylea
Fabrazyme
Factor for treating Hemophilia
Faslodex
Filgrastim
Firazyr
Flebogamma
Flolan
Fluocinolone intravitreal implant
Folotyn
Fondaparinux
Forteo
Fosaprepitant
Fragmin
Fulvestrant
Fusilev
Galsulfase
Gammagard (IV)
Gammagard (Subcutaneous)
Gammaked (IV)
Gammaked (Subcutaneous)
Gammaplex
Gammar-P
Gammunex-C
Gamunex
Gattex
Gazyva
Gel One
Glatiramer
Golimumab
Granix
Grastek
Growth Hormone Adult
Growth Hormone Child
Halaven
Herceptin
Histrelin Implant (Supprelin LA)
Histrelin Implant (Vantas)
Hizentra
Humira
Hyalgan
Hyqvia
Ibandronate
Icatibant
Idursulfase
Ilaris
Iloprost
Iluvien
Imiglucerase
Imitrex
Immune Globulin (Subcutaneous)
IncobotulinumtoxinA
Increlex
Infergen for Hepatitis C
Infliximab
Innohep
Interferon Alfa for Hepatitis C
Interferon Alfa-2b (Intron-A)
Interferon Alfa-n3 (Aleferon-N)
Interferon Alfacon-1
Interferon Gamma 1b
Intron-A
Invega Sustenna
Invega Trinza
Ipilimumab
Iprivask
Istodax
IV Antibiotics for Tick Borne Infections
IVIG (Intravenous)
IVIG (Subcutaneous)
Ixabepilone
Ixempra
Jetrea
Jevtana
Kadcyla
Kalbitor
Kepivance
Keytruda
Kineret
Krystexxa
Kynamro
Kyprolis
Lanreotide
Lemtrada
Leukine
Levoleucovorin
Linezolid
Lovenox
Lucentis
Lumizyme
Lyme Disease
Macugen
Makena
Marqibo
Mecaserim
Methoxypolyethylene glycol-epoetin beta
Methylnaltrexone
Metreleptin
Miacalcin
Micafungin
Mipomersin
Mircera
Monovisc
Mozobil
Myalept
Mycamine
Myobloc
Myozyme
Naglazyme
Naltrexone
Natalizumab
Neulasta
Neumega
Neupogen
Nivolumab
Noxafil
Nplate
Nulojix
Obinutuzumab
Ocriplasmin
Octagam
Octreotide
Ofatumamab
Olanzapine
Omacetaxine
Omalizumab
OnobotulinumtoxinA
Opdivo
Oprelvekin
Orbactiv
Oralair
Orencia
Oritavancin
Orthovisc
Ozurdex
Paclitaxel Protein Bound Suspension
Palifermin
Paliperidone
Palivizumab
Palonosetron
Panitumumab
Pasireotide
Pegaptanib
Pegasys for Hepatitis C
Peg-Intron for Hepatitis C
Pegfilgrastim
Peginterferon Alfa 2B (Sylatron)
Pegloticase
Pegvisomant
Pembrolizumab
Pemetrexed
Penicillin G
Peramivir
Perjeta
Pertuzumab
Plerixafor
Posaconazole
Pralatrexate
Praluent
Prialt
Procrit
Proleukin
Prolia
Qutenza
Ragwitek
Ramucirumab
Ranibizumab
Rapivab
Rebif
Reclast
Relistor
Remicade
Remodulin
Repatha
Retisert
Revatio
Rilonacept
RimabotulinumtoxinB
Risperdal Consta
Risperidone
Rituxan
Rituximab
Rocephin
Romidepsin
Romiplostim
Ruconest
Sandostatin LAR
Sargramostim
Secukinumab
Serostim
Signifor/Signifor LAR
Sildenafil
Siltuximab
Simponi
Sivextro
Soliris
Somatropin
Somatuline
Somavert
Stelara
Sublingual allergen immunotherapy
Sumatriptan
Sumavel DosePro
Supartz
Supprelin LA
Sylatron
Sylvant
Synagis
Synribo
Synvisc
Synvisc One
Taliglucerase
Tbo-filgrastim
Tedizolid
Teduglutide
Temodar
Temozolomide
Temsirolimus
Teriparatide
Tesamorelin
Testosterone undecanoate
Tinzaparin

Tocilizumab

Torisel
Trastuzumab
Treanda
Treprostinil
Tysabri
Tyvaso
Ustekinumab
Vantas
Vectibix
Vedolizumab
Velaglucerase
Velcade
Veletri
Ventavis
Vidaza
Vimizim
Vincristine liposome
Viscosupplements
Vivitrol
VPRIV
Xeomin
Xgeva
Xiaflex
Xolair
Yervoy
Zaltrap
Zarxio
Ziconotide
ZIV-Aflibercept
Zoledronic Acid
Zometa
Zyprexa Relprevv
Zyvox

Oral/Topical Drugs

File Name
Drug Prior Authorization Request Form (CA PA Request Form)
Blue Shield Prescription Coverage Request Form - Oral/Topical Medications
Actonel
Actonel for Paget's
Adcirca
Adempas
Adipex-P
Afinitor
Alinia
Altoprev
Amerge
Amitiza for Constipation
Amitiza for IBS
Ampyra
Anadrol
Androderm
Androgel
Android
Angiotensin Receptor Blockers (ARBs)
Anzemet
Apidra
Aptivus
Arimidex
Aromasin
Atacand/Atacand HCT
Atelvia
Avandaryl
Avandia
Avodart
Axert
Axiron
Belviq
Benicar/Benicar HCT
Bethkis
Bidil
Binosto
Blood Glucose Test Strips
Boniva
Bontril PDM
Bosulif
Bowel Preparation Agents
Brand Name only
Brovana
Bunavail
Butorphanol NS
Butrans
CalPERS Non-Formulary Copayment Reduction
Caprelsa
Cayston
Celebrex
Cerdelga
Cesamet
Cholbam
Cialis for Erectile Dysfunction
Clarinex/Clarinex-D
Clobex
Compounded Drugs
Contrave ER
Conzip
Corlanor
Crinone 4%/Crinone 8%
Daklinza
Daliresp
Daytrana
Didrex
Diethylpropion
Dificid
Diovan
Drugs to Avoid in the Elderly
Duetact
Duragesic
Edarbi
Edarbyclor
Embeda
Emend
Emsam
Endometrin
Entresto
Epivir HBV
Erivedge
Esbriet
Evista
Exalgo
Exforge/Exforge HCT
Farydak
Fastin
Femara
Fentora
Fexmid
First-Testosterone
Flector
Fortesta
Fortical
Fosamax Plus D
Fosamax Plus D for Paget's
Frova
Fulyzaq
Glumetza
Harvoni
Helidac
Hetlioz
Hexalen
Hysingla ER
Ibrance
Iclusig
Imbruvica
Imitrex
Inlyta
Intelence
Intermezzo
Ionamin
Intraconazole
Iressa
Jakafi
Juxtapid
Kadian
Kalydeco
Kitabis PAK
Korlym
Kuvan
Kynamro
Kytril
Lamisil Granules
Lenvima
Lescol/Lescol XL
Letairis
Levitra (Formulary)
Linzess for Constipation
Linzess for IBS
Livalo
Lotronex
Lovaza
Lynparza
Lyrica
Maxalt
Mekinist
Member Paid Difference
Mepron
Methitest
Miacalcin NS
Micardis/Micardis HCT
Migranal NS
Mirapex ER
Moderiba
Movantik
Muse
Narcotics
Narcotic Agents, Extended Release
Nascobal
Nexavar
Noxafil
Nuvigil
Nuvigil: Use for Depression
Ofev
Olux/Olux-E
Olysio
Omeclamox Pak
Onmel
Opana
Opana ER
Orkambi
Otezla for Psoriasis
Oxandrin
Pennsaid Soltuion
Perforomist
Phentermine
Prandimet
Procentra
Proglycem
Promacta
Proventil HFA
Provigil
Provigil: Use in Depression
Pylera
Qsymia
Quantity Limits Exceeded
Ranexa
Rebetol
Regimex
Regranex
Relenza
Relpax
Revatio
Revlimid
Ribavirin
Samsca
Sancuso
Saphris
Selzentry
Sensipar
Sivextro
Solodyn
Soltamox
Sovaldi
Sporanox
Sprix
Sprycel
Stadol NS
Suboxone
Subutex
Suprenza
Sutent
Tafinlar
Tamiflu
Tarceva
Tasigna
Technivie
Tenuate
Testim
Testred
Testosterone Replacement
Teveten/Teveten HCT
TOBI
Tracleer
Tramadol ER
Treximet
Tribenzor
Twynsta
Tykerb
Tyzeka
Vascepa
Veregen
Vfend
Viagra
Viagra for PAH
Viekira
Voltaren Gel
Votrient
Vytorin
Weight Loss Agents
Xalkori
Xartemis XR
Xenazine
Xenical
Xifaxan
Xopenex HFA
Xyrem
Xyzal
Zavesca
Zetia
Zohydro ER
Zomig
Zubsolv
Zuplenz
Zytiga
Zyvox

Commercial Procedures/HCPCS

File Name
General Request
General Request eviCore
Accelerated Breast Irradiation After Breast-Conserving Surgery for Early Stage Breast Cancer and Breast Brachytherapy as Boost With Whole-Breast Irradiation
Actigraphy
Artificial Intervertebral Disc: Cervical Spine
Artificial Intervertebral Disc: Lumbar Spine
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Auditory Brainstem Implant
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
Automated Percutaneous and Endoscopic Discectomy
Axial Lumbosacral Interbody Fusion
Balloon Ostial Dilation for Treatment of Chronic Sinusitis
Bariatric Surgery
Beta-Amyloid Imaging with Positron Emission Tomography for Alzheimer Disease
Biofeedback as a Treatment of Urinary Incontinence in Adults
Blepharoplasty, Blepharoptosis Repair (levator resection) and Brow Lift (repair of brow ptosis)
Bone Morphogenetic Protein
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
Cardiac Applications of Positron Emission Tomography Scanning
Cervical Spinal Fusion
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Clinical Trial (for any indication)
Cochlear Implant
Computer-Aided Evaluation of Malignancy With Magnetic Resonance Imaging of the Breast
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
Continuous Passive Motion in the Home Setting
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
Deep Brain Stimulation
Dental Anesthesia
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Diagnosis and Treatment of Sacroiliac Joint Pain
Discectomy
Discography
Electrical Bone Growth Stimulation of the Appendicular Skeleton
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
Electrostimulation and Electromagnetic Therapy for Treating Wounds
Endobronchial Brachytherapy
Epidural Steroid Injections for Back Pain
External Insulin Infusion Pump
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
Facet Arthroplasty
Facet Joint Denervation
Facet Joint Injections and Facet Joint Nerve Blocks
Functional Neuromuscular Electrical Stimulation
Gastric Electrical Stimulation
Gender Reassignment Surgery
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (BRCA1/BRCA2)
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Genetic Testing for Inherited Thrombophilia
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Genetic Testing of CADASIL Syndrome
High-Dose Rate Temporary Prostate Brachytherapy
Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease
Hyperbaric Oxygen Therapy
Hysterectomy Surgery
Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis
Implantable Bone-Conduction and Bone-Anchored Hearing Aids
Implantable Cardioverter Defibrillator
Implantable Infusion Pump
Implantation of Intrastromal Corneal Ring Segments
Injectable Bulking Agents
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Intensity Modulated Radiation Therapy (Generic IMRT)
Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
Knee Arthroplasty for Adults
Knee Braces
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer
Laboratory Tests for Heart Transplant Rejection
Laminectomy
Lower Limb Prostheses
Lumbar Spinal Fusion
Lysis of Epidural Adhesions
Magnetic Resonance Imaging of the Breast
Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
Microprocessor Controlled Lower Limb Prostheses
Microwave and Locoregional Laser Tumor Ablation
Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorodeoxyglucose F 18 Positron Emission Tomography
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Negative Pressure Wound Therapy in the Outpatient Setting
Neuropsychological Testing
Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Occipital Nerve Stimulation
Oncologic Applications of Positron Emission Tomography Scanning
Orthognathic Surgery
Orthopedic Applications of Platelet-Rich Plasma
Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow)
Orthoptic Training for the Treatment of Vision or Learning Disabilities
Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation
Percutaneous Intradiscal Electrothermal Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty
Percutaneous Tibial Nerve Stimulation
Percutaneous Vertebroplasty and Sacroplasty
Physical Therapy Treatment - eBay/PayPal
Positron Emission Mammography
Power Wheelchairs and Power Operated Vehicles for Permanent Use
Prolotherapy
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Reduction Mammaplasty for Breast-Related Symptoms
Regional Sympathetic Blocks
Sacral Nerve Neuromodulation/Stimulation
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Spinal Cord Stimulation
Surgical Deactivation of Headache Trigger Sites
Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea
Surgical Treatment of Bilateral Gynecomastia
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Temporomandibular Joint Dysfunction
Total Hip Arthroplasty for Adults
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Treatment of Varicose Veins/Venous Insufficiency
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Vagus Nerve Stimulation
Vertebral Axial Decompression
Virtual Colonoscopy/Computed Tomography Colonography
Wearable Cardioverter Defibrillator
Whole Gland Cryoablation of Prostate Cancer
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon

FEP Procedures

File Name
General Request
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 Sinusitis
Bariatric Surgery
Bio-Engineered Skin And Soft Tissue Substitutes
Biofeedback
Biventricular Pacemakers (Cardiac Resynchronization) for the Treatment of Heart Failure
Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)
Bone Mineral Density Studies
Bone Morphogenetic Protein
BOTOX
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
Brachytherapy for Oncologic Indications
Cancer Clinical Trial
Cochlear Implant
Cognitive Rehabilitation
Congenital Anomalies
Cryosurgical Ablation of Miscellaneous Solid Tumors
Cryosurgical Ablation of Prostate Cancer
CT Colonography
Deep Brain Stimulation
Electrical Bone Growth Stimulation
Endoscopic Injection
Epidural Steroid Injections
External Insulin Pump
Facet Joint Injections and Facet Joint Blocks
Gastrointestinal Motility and Manometry Testing
Gene Expression Profiling
General Anesthesia
General Request
Genetic Testing for Colorectal Cancer Risk
Genetic Testing for Hereditary Breast and Ovarian Cancer
Gynecomastia
Hyperbaric Oxygen Therapy
Implantable Middle Ear and Bone-Anchored Hearing Aids
Implantation of Intrastromal Corneal Ring Segments
Incontinence Treatment System
Injectable Bulking Agent
Knee Braces
Lower Limb Prostheses
MRI of Breast
Negative Pressure Wound Therapy in the outpatient setting
Neuromuscular and Functional Electrical Stimulation
Neuropsychological Testing
Oral/Maxillofacial
Orthognathic Surgery
Orthoptic Training
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Diseases
Panniculectomy Abdominoplasty
Positron Emission Tomography (PET)
Power Wheelchair
Radioembolization of Liver Tumors (SIRT)
Radiofrequency Ablation of Solid Tumors Excluding Liver Tumors
Sacroiliac Joint Injections
Transurethral Radiofrequency
UVPP UPPP
Varicose Vein Treatments
Wearable Cardioverter Defibrillator
Wireless Capsule Endoscopy