
Medication Authorization Request Forms for Drugs Covered Under the Medical Benefit
On this page you'll find information for:
- BCN HMOSM (commercial)
- BCN AdvantageSM
- Blue Cross commercial
- Blue Cross Medicare Plus BlueSM PPO
- Blue Cross Federal Employee Program®
BCN HMOSM (Commercial) Forms | |
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Blue Cross 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. |
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* 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 | |
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Blue Cross Medicare Plus BlueSM PPO Forms | |
Go to the BCN Advantage medical drug policies and forms page. |
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Go to the Medicare Advantage PPO medical drug policies and forms page. |
Blue Cross Federal Employee Program® | |
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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. |
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