To submit a prior authorization online, please click the button below to use the web form.
PDF forms are available below to submit a prior authorization through fax.
| Title | Categories | Update Date | Download |
|---|---|---|---|
|
Compounding Coverage Authorization Request Form 1 1543 downloads |
BCBSAL | December 3, 2020 | Download |
|
FDA Medwatch Form 1 1271 downloads |
90degrees, affirmedrx, BCBSAL, BCBSFL, BCBSMN, Credence, HiLab, oreadrx, pcarx, rxsense, verusrx | August 31, 2023 | Download |
|
General-PA Form 1 27386 downloads |
BCBSAL | November 11, 2021 | Download |
|
Opioid PA-Request Form 1 1610 downloads |
BCBSAL | November 11, 2021 | Download |
|
Part D Form 1 836 downloads |
BCBSAL | December 4, 2020 | Download |
|
Pegasys 1 120 downloads |
BCBSAL | November 11, 2021 | Download |
|
Suboxone Subutex Prior Authorization Request Form 1 514 downloads |
BCBSAL | November 11, 2021 | Download |
|
Substance Abuse Authorization Form 1 181 downloads |
BCBSAL | November 11, 2021 | Download |
|
TNF Biologic PA Form 1 2206 downloads |
BCBSAL | November 11, 2021 | Download |