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 file(s) 49 downloads |
BCBSAL | December 3, 2020 | Download |
FDA Medwatch Form 1 file(s) 47 downloads |
BCBSAL, BCBSFL, HiLab, sscripts | December 15, 2020 | Download |
FDA MedWatch Form 3500 1 file(s) 9 downloads |
BCBSAL | December 15, 2020 | Download |
General-PA Form 1 file(s) 1054 downloads |
BCBSAL | December 4, 2020 | Download |
Opioid PA-Request Form 1 file(s) 126 downloads |
BCBSAL | December 4, 2020 | Download |
Part D Form 1 file(s) 33 downloads |
BCBSAL | December 4, 2020 | Download |
Pegasys 1 file(s) 6 downloads |
BCBSAL | December 4, 2020 | Download |
Specialty Pharmacy Form 1 file(s) 380 downloads |
BCBSAL | December 4, 2020 | Download |
Suboxone Subutex Prior Authorization Request Form 1 file(s) 38 downloads |
BCBSAL | December 4, 2020 | Download |
Substance Abuse Authorization Form 1 file(s) 5 downloads |
BCBSAL | December 4, 2020 | Download |
Synagis Authorization Request Form 1 file(s) 13 downloads |
BCBSAL | December 4, 2020 | Download |
TNF Biologic PA Form 1 file(s) 90 downloads |
BCBSAL | December 4, 2020 | Download |