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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
General Office Injectable
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
General Oral/Topical Drug
Abilify
Actonel
Actonel for Paget's
Actos
Adcirca
Adipex-P
Afinitor
Alinia
Altoprev
Amerge
Amitiza for Constipation
Amitiza for IBS
Ampyra
Anadrol
Androderm
Anzemet
Apidra
Aptivus
Arimidex
Aromasin
Atacand
Avalide
Avandaryl
Avandia
Avapro
Avinza
Avodart
Axert
Axiron
Azasan
Benicar
Bidil
Blood Glucose Test Strips
Boniva
Brand Name only
Brovana
Butorphanol NS
Campral
Caprelsa
Cayston
Celebrex
Cesamet
Cialis
Clarinex/Clarinex-D
Clobex
Complera
Compounded Drugs
Crestor
Crinone 8%
Daliresp
Daytrana
Detrol/Detrol LA
Diethylpropion
Dificid
Diovan
Drugs to Avoid in the Elderly
Duetact
Duoneb
Duragesic
Edurant
Effient
Emend
Emsam
Enablex
Endometrin
Epivir HBV
Erivedge
Evista
Exalgo
Fastin
Femara
Fexmid
First-Progesterone VGS
Flector
Fortical
Fosamax Oral Solution
Frova
Gelnique
Geodon
Glumetza
Helidac
Hexalen
Imitrex
Imuran
Incivek
Inlyta
Intelence
Intermezzo
Ionamin
Iressa
Isentress
Intraconazole
Jakafi
Janumet
Kadian
Kalydeco
Korlym
Kuvan
Kytril
Lamisil Granules
Lescol/Lescol XL
Letairis
Levitra (Formulary)
Liquadd
Lotronex
Lovaza
Lyrica
Maxalt
Member Paid Difference
Mepron
Miacalcin NS
Micardis
Migranal NS
Multaq
Muse
Narcotics
Nascobal
Nexavar
Nexium
Noxafil
Nuvigil
Nuvigil: Use for Depression
Olux/Olux-E
Ondansetron
Opana
Opana ER
Orapred ODT
Oravig
Oxycontin
Oxytrol
Perforomist
Phentermine
Prandimet
Prandin
Prevacid Solutab
Prevpac
Prezista
Prilosec Suspension
Procentra
Proglycem
Promacta
Proventil HFA
Provigil
Provigil: Use in Depression
Pylera
Quantity Limits Exceeded
Ranexa
Rapaflo
Rebetol
Regranex
Relenza
Relpax
Renvela
Requip XL
Revatio
Revlimid
Ribavirin
Rybix ODT
Samsca
Sanctura/Sanctura XR
Sancuso
Saphris
Selzentry
Sensipar
Seroquel
Solodyn
Soltamox
Sporanox
Stadol NS
Starlix
Suboxone
Subutex
Sutent
Tamiflu
Tarceva
Tasigna
Tenuate
Testosterone Replacement
Teveten
Tindamax
TOBI
Toviaz
Tracleer
Treximet
Tykerb
Tyzeka
Ultravate PAC
Veregen
Vesicare
Vfend
Viagra
Viagra for PAH
Victrelis
Voltaren Gel
Votrient
Vytorin
Xenazine
Xenical
Xifaxan
Xopenex
Xyrem
Xyzal
Zavesca
Zegerid
Zelapar
Zetia
Zofran
Zomig
Zortress
Zuplenz
Zytiga
Zyvox