Medication Authorization Request Forms for Drugs Covered Under the Medical Benefit

On this page you'll find information for:

BCN HMOSM (Commercial) Forms
Blue Cross PPO (Commercial) 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.

* Note: The drugs that have an asterisk are no longer on Prior Authorization. The form should only be used if requesting a retro prior authorization for the drug.


BCN AdvantageSM Forms
Blue Cross Medicare Plus BlueSM PPO Forms

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

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