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) 586 downloads |
BCBSAL | November 16, 2016 | Download |
|
FDA Medwatch Form 1 file(s) 1245 downloads |
BCBSAL, BCBSFL, HiLab, HWMG, RxBenefits, sscripts | May 14, 2019 | Download |
|
FDA MedWatch Form 3500 1 file(s) 174 downloads |
BCBSAL | May 15, 2017 | Download |
|
General-PA Form 1 file(s) 390 downloads |
BCBSAL | August 17, 2020 | Download |
|
Opioid PA-Request Form 1 file(s) 33 downloads |
BCBSAL | August 17, 2020 | Download |
|
Part D Form 1 file(s) 709 downloads |
BCBSAL | November 16, 2016 | Download |
|
PCSI 10 1 file(s) 8 downloads |
BCBSAL | August 17, 2020 | Download |
|
Pegasys 1 file(s) 4 downloads |
BCBSAL | August 17, 2020 | Download |
|
Specialty Pharmacy Form 1 file(s) 3351 downloads |
BCBSAL | November 16, 2016 | Download |
|
Suboxone Subutex Prior Authorization Request Form 1 file(s) 14 downloads |
BCBSAL | August 17, 2020 | Download |
|
Substance Abuse Authorization Form 1 file(s) 1 download |
BCBSAL | August 17, 2020 | Download |
|
Synagis Authorization Request Form 1 file(s) 116 downloads |
BCBSAL | November 16, 2016 | Download |