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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 here: Blue Shield 65 Plus Request for Prior Authorization/Referral Form (PDF, 49KB).

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Drug Prior Authorization Request for:

Commercial Procedures/HCPCS

File Name
General Request
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer
Actigraphy
Auditory Brainstem Implant
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis
Bariatric Surgery
Beta-Amyloid Imaging with Positron Emission Tomography for Alzheimer Disease
Biofeedback as a Treatment of Urinary Incontinence in Adults
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
Cardiac Applications of Positron Emission Tomography Scanning
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
Computed Tomography to Detect Coronary Artery Calcification
Computed Tomography Perfusion Imaging of the Brain
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
Continuous Passive Motion in the Home Setting
Contrast-Enhanced Coronary Computed Tomography Angiography for Coronary Artery Evaluation
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
Dental Anesthesia
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Elective Revascularization Utilizing Percutaneous Coronary Intervention for Non- Acute, Stable Coronary Artery Disease
Electrostimulation and Electromagnetic Therapy for Treating Wounds
Endobronchial Brachytherapy
External Insulin Infusion Pump
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
Functional Neuromuscular Electrical Stimulation
Gender Reassignment Surgery
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Genetic Testing for Hereditary Breast / Ovarian Cancer Syndrome (BRCA1 or 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 for Mitochondrial Disorders
Genetic Testing of CADASIL Syndrome
High-Dose Rate Temporary Prostate Brachytherapy
Hyperbaric Oxygen Therapy
Hysterectomy Surgery
Implantable Bone-Conduction and Bone-Anchored Hearing Aids
Implantable Cardioverter Defibrillator
Implantation of Intrastromal Corneal Ring Segments
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
Lower Limb Prostheses
Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer
Magnetic Resonance Imaging of the Breast
Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants
Magnetic Resonance Spectroscopy
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
NIA Pain/Spine
NIA Radiology
Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
Nonpharmacologic Treatment of Rosacea
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
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 Tibial Nerve Stimulation
Percutaneous Vertebroplasty and Sacroplasty
Physical Therapy- Applies to eBay only
Positron Emission Mammography
Power Wheelchairs and Power Operated Vehicles for Permanent Use
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Reconstructive Services
Reduction Mammaplasty for Breast-Related Symptoms
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Subtalar Arthroereisis
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
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
Urgent Expedited Request
Virtual Colonoscopy/Computed Tomography Colonography
Wearable Cardioverter Defibrillators
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
Whole Gland Cryoablation of Prostate Cancer
Wireless Capsule Endoscopy to Diagnose 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
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions
Avastin
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
Botox
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
Brachytherapy for Oncologic Indications
Cardiac Applications of Positron Emission Scanning
Cardiovascular Risk Panels
Catheter Ablation for Cardiac Arrhythmias
Chromoendoscopy as an Adjunct to Colonoscopy
Cleft Palate Dental Related Services
Clinical Trial (for any indication)
Cochlear Implant
Cognitive Rehabilitation
Congenital Anomalies
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
Cranial Electrotherapy Stimulation and Auricular Electrostimulation
Cryosurgical Ablation of Miscellaneous Solid Tumors
Cryosurgical Ablation of Prostate Cancer
CT Colonography (Virtual Colonoscopy)
Deep Brain Stimulation
Dermatologic Applications of Photodynamic Therapy
Detection of Circulating Tumor Cells in the Management of Patients with Cancer
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography
Electrical Bone Growth Stimulation
Emend
Endoscopic Injection
Enhanced External Counterpulsation
Entyvio
Epogen Procrit
External Insulin Infusion Pump
Gastrointestinal Motility and Manometry Testing
Functional Neuromuscular Electrical Stimulation
Gastrointestinal Motility and Manometry Testing
Gene Expression Profiling for Managing Breast Cancer Treatment
General Anesthesia for Routine Dental Procedures performed in an Outpatient Surgery Center or Facility
General Request
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Genetic Testing for Colorectal Cancer
Genetic Testing for Hereditary Breast and/or Ovarian Cancer
Gynecomastia Surgery
Hyaluronic Acid Agents
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