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) 559 downloads |
BCBSAL | November 16, 2016 | Download |
|
FDA Medwatch Form 1 file(s) 1208 downloads |
BCBSAL, BCBSFL, HiLab, HWMG, RxBenefits, sscripts | May 14, 2019 | Download |
|
FDA MedWatch Form 3500 1 file(s) 165 downloads |
BCBSAL | May 15, 2017 | Download |
|
General PA Form 1 file(s) 21665 downloads |
BCBSAL | November 16, 2016 | Download |
|
Opioid PA Request Form 1 file(s) 1541 downloads |
BCBSAL | March 29, 2018 | Download |
|
Part D Form 1 file(s) 688 downloads |
BCBSAL | November 16, 2016 | Download |
|
PCSI 10 1 file(s) 577 downloads |
BCBSAL | November 16, 2016 | Download |
|
Pegasys 1 file(s) 127 downloads |
BCBSAL | November 16, 2016 | Download |
|
Specialty Pharmacy Form 1 file(s) 3184 downloads |
BCBSAL | November 16, 2016 | Download |
|
Suboxone Subutex Prior Authorization Request Form 1 file(s) 649 downloads |
BCBSAL | November 16, 2016 | Download |
|
Substance Abuse Authorization Form 1 file(s) 116 downloads |
BCBSAL | November 16, 2016 | Download |
|
Synagis Authorization Request Form 1 file(s) 111 downloads |
BCBSAL | November 16, 2016 | Download |