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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 and Direct Contracting by using the forms below:

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Office Administered Drugs

File Name
Blue Shield Prescription Coverage Request Form – Medical Drugs
17-alphahydroxyprogesterone (17P)
Abatacept
AbobotulinumtoxinA
Abraxane
Actemra
Acthar
Adalimumab
Adalimumab for Psoriasis
Adcetris
Ado-Trastuzumab emtansine
Aflibercept
Agalsidase beta
Aglucosidase alfa
Aldesleukin
Alferon-N
Alglucerase
Alimta
Aloxi
Anakinra
Anidulafungin
Anzemet
Aranesp
Arcalyst
Arixtra
Arzerra
Asparaginase
Avastin
Avonex
Azacitidine
Belatacept
Belimumab
Bendamustine
Benlysta
Berinert
Betaseron
Bevacizumab
Bivigam
Boniva
Bortezomib
Botox
Botulinum Toxin Type A
Botulinum Toxin Type B
Brentuximab
C1 Inhibitor
Cabazitaxel
Calcitonin Salmon
Canakinumab
Cancidas
Capsaicin 8% Patch
Carfilzomib
Carimune
Caspofungin
Cefotaxime
Ceftriaxone
Ceredase
Cerezyme
Certolizumab pegol
Cetuximab
Cimzia
Cinryze
Claforan
Clofarabine
Clolar
Collagenase
Copaxone
Corticotropin
Cytogam
Dacogen
Dalteparin
Darbepoetin alfa
Decitabine
Denosumab (Prolia,Xgeva)
Desiriduin
D.H.E. 45
Dihydroergotamine
Dolasetron
Dysport
Ecallantide
Eculizumab
Egrifta
Elaprase
Elelyso
Emend
Enbrel for Psoriasis
Enbrel for RA, PA, AS
Enoxaparin
Epoetin
Epogen
Epoprostenol
Eraxis
Erbitux
Eribulin
Erwinase
Erythropoietin
Etanercept for Psoriasis
Etanercept for RA, PA, AS
Euflexxa
Extavia
Eylea
Fabrazyme
Factor for treating Hemophilia
Faslodex
Filgrastim
Firazyr
Flebogamma
Flolan
Folotyn
Fondaparinux
Forteo
Fosaprepitant
Fragmin
Fulvestrant
Fusilev
Galsulfase
Gammagard (IV)
Gammagard (Subcutaneous)
Gammaked (IV)
Gammaked (Subcutaneous)
Gammaplex
Gammar-P
Gammunex-C
Gamunex
Gattex
Gel One
Golimumab
Growth Hormone Adult
Growth Hormone Child
Halaven
Hepatitis-C
Herceptin
Histrelin Implant (Supprelin LA)
Histrelin Implant (Vantas)
Hizentra
Humira
Humira for Psoriasis
Hyalgan
Ibandronate
Icatibant
Idursulfase
Ilaris
Iloprost
Imiglucerase
Imitrex
Immune Globulin (Subcutaneous)
IncobotulinumtoxinA
Increlex
Infergen for Hepatitis C
Infliximab for Crohn's Disease and Ulcerative Colitis
Infliximab for Psoriasis, RA, PA, AS
Innohep
Interferon Alfa for Hepatitis C
Interferon Alfa-2b (Intron-A)
Interferon Alfa-n3 (Aleferon-N)
Intron-A
Invega Sustenna
Ipilmumab
Iprivask
Irinotecan
Istodax
IV Antibiotics for Lyme Disease
IVIG (Intravenous)
IVIG (Subcutaneous)
Ixabepilone
Ixempra
Jetrea
Jevtana
Kadcyla
Kalbitor
Kepivance
Kineret
Kyrstexxa
Kynamro
Kyprolis
Leukine
Levoleucovorin
Linezolid
Lovenox
Lucentis
Lumizyme
Lyme Disease
Macugen
Makena
Marqibo
Mecaserim
Methylnaltrexone
Miacalcin
Micafungin
Mipomersin
Mozobil
Mycamine
Myobloc
Myozyme
Naglazyme
Naltrexone
Natalizumab
Neulasta
Neumega
Neupogen
Nplate
Nulojix
Ocriplasmin
Octagam
Octreotide
Ofatumamab
Omalizumab
Olanzapine
Omacetaxine
Omalizumab
OnobotulinumtoxinA
Oprelvekin
Orencia
Orthovisc
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
Pemetrexed
Penicillin G
Perjeta
Pertuzumab
Plerixafor
Pralatrexate
Prialt
Procrit
Proleukin
Prolia
Qutenza
Ranibizumab
Reclast
Relistor
Remicade for Crohn's Disease and Ulcerative Colitis
Remicade for Psoriasis, RA, PA, AS
Remodulin
Revatio
Rilonacept
RimabotulinumtoxinB
Risperdal Consta
Risperidone
Rituxan
Rituximab
Rocephin
Romidepsin
Romiplostim
Sandostatin LAR
Sargramostim
Serostim
Sildenafil
Simponi
Soliris
Somatropin
Somavert
Stelara
Sumatriptan
Sumavel DosePro
Supartz
Supprelin LA
Sylatron
Synagis
Synribo
Synvisc
Synvisc One
Taliglucerase
Teduglutide
Temodar
Temozolomide
Temsirolimus
Teriparatide
Tesamorelin
Tinzaparin
Tocilimuzab
Torisel
Trastuzumab
Treanda
Treprostinil
Tysabri
Tyvaso
Ustekinumab
Vantas
Vectibix
Velaglucerase
Velcade
Veletri
Ventavis
Vidaza
Vincristine liposome
Viscosupplements
Vivitrol
VPRIV
Xeomin
Xgeva
Xiaflex
Xolair
Yervoy
Zaltrap
Ziconotide
ZIV-Aflibercept
Zoledronic Acid (Reclast)
Zoledronic Acid (Zometa)
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
Abilify
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
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%
Daliresp
Daytrana
Didrex
Diethylpropion
Dificid
Diovan
Drugs to Avoid in the Elderly
Duetact
Duragesic
Edarbi
Edarbyclor
Embeda
Emend
Emsam
Endometrin
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
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
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
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
Accelerated Breast Irradiation After Breast-Conserving Surgery for Early Stage Breast Cancer and Breast Brachytherapy as Boost With Whole-Breast Irradiation
Actigraphy
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
Balloon Ostial Dilation for Treatment of Chronic Sinusitis
Bariatric Surgery
Behavioral Health Treatment for Pervasive Developmental Disorders
Bio-Engineered Skin and Soft Tissue Substitutes
Blepharoplasty, Blepharoptosis Repair, and Brow Lift
Bone Mineral Density and Vertebral Fracture Assessment
Breast Duct Cytology and Endoscopy
Cancer Clinical Trial
Charged-Particle (Proton or Helium) Radiation Therapy
Cochlear and Auditory Brainstem Implants
Computer-Aided Evaluation of Malignancy With Magnetic Resonance Imaging of the Breast
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
Continuous Passive Motion in the Home Setting
Coronary Heart Disease (CHD)-Assessment of Emerging Risk Factors
Cranial Remodeling Orthosis
Cryosurgical Ablation of Miscellaneous Solid Tumors
Cryosurgical Ablation of Prostate Cancer
Deep Brain Stimulation
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Electrical Bone Growth Stimulation of the Appendicular Skeleton
Exhaled Nitrous Oxide and Exhaled Breath Condensate Measurement for Respiratory Disorders
External Insulin Infusion Pump
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
Gastrointestinal Motility and Manometry Testing
Gene Based Tests for Screening, Detection and Management of Prostate Cancer
Gender Reassignment Surgery
General Anesthesia for a Dental Procedure
Genetic Testing for Hereditary Breast and Ovarian Cancer
Genetic Testing for Inherited Thrombophilia
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Gynecomastia Surgery-Male Breast Reduction
Hyperbaric Oxygen Therapy (HBOT)
Implantable Cardioverter Defibrillator
Implantable Middle Ear and Bone-Anchored Hearing Aids
Implantation of Intrastromal Corneal Ring Segments
Intensity Modulated Radiation Therapy (IMRT)
Knee Braces
Laser, Light Therapy, and Cryotherapy for Acne Vulgaris
Lower Limb Prostheses
Magnetic Resonance Imaging to Monitor Integrity of Silicone-Gel-Filled Breast Implants
Maternal Plasma Cell-free Fetal DNA Sequencing for Fetal Aneuploidy Detection
Microprocessor Controlled Lower Limb Prostheses
Monitored Anesthesia Care (MAC)
MRI of the Breast
Negative Pressure Wound Therapy in the Outpatient Setting
Neuromuscular, Functional and Threshold Electrical Stimulation
Neuropsychological Testing
Orthognathic Surgery
Orthoptic Training
Panniculectomy, Abdominoplasty and Surgical Management of Diastasis Recti
Positron Emission Tomography (PET)
Power Wheelchairs and Power Operated Vehicles
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Speech Therapy Treatment
Spinal Surgery/Injections/Implants/Devices TRIAD fax form
Surgical Deactivation of Headache Trigger Sites
Transcranical Magnetic Stimulation (TMS)
Treatment of Varicose Veins/Venous Insufficiency
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Urinary Incontinence
Virtual Colonoscopy/Computed Tomography Colonography
Wearable Cardioverter Defibrillator
Wireless Capsule Endoscopy

FEP Procedures

File Name
Autologous Chondrocyte Implantation
Bariatric Surgery
Biofeedback
Blepharoplasty
Brachytherapy
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