Medication Authorization Request Forms for Drugs Covered Under the Medical Benefit

On this page you'll find information for:

BCN Commercial Forms
Blue Cross Commercial Forms

Use the appropriate Medication Authorization Request Form below to request prior authorization for a medication that's covered under a member's medical benefits and administered in an outpatient location.

Providers located outside of Michigan who don’t have access to the NovoLogix® online tool must request access by completing the Application for access to NovoLogix for non-Michigan prescribers and submitting it along with the Medication Authorization Request Form. If we approve your application, we’ll provide instructions for how to use NovoLogix to submit subsequent prior authorization requests.
* Note: The drugs that have an asterisk no longer require prior authorization. The form should be used only when requesting a retroactive authorization for the drug.

 

BCN AdvantageSM Forms
Medicare Plus BlueSM Forms

Go to the BCN Advantage medical drug policies and forms page.

Go to the Medicare Advantage medical drug policies and forms page.

 

Blue Cross and Blue Shield Federal Employee Program® Forms

Use these forms to obtain prior authorization for administering medications in physician's offices and outpatient hospitals, including urgent care, hospital-based infusion care centers, and clinics where the drug is injected or infused and billed on a UB04 or CMS 1500 form.