Self-Administered Drug Prior Authorization Forms

Drug policies are based on:

• information in FDA-approved package inserts (and black box warnings, alerts or other information disseminated by the FDA, as applicable);
• research of current medical and pharmacy literature; and/or,
• review of common medical practices in the treatment and diagnosis of disease.

Note: Coverage is subject to the member's specific benefits. Group-specific benefits will supersede these policies when applicable. Always check eligibility and benefits through your local Blue Plan provider portal or your practice management system to confirm member-specific benefits.

Forms

Click on the appropriate link below to print the form to request prior authorization for these drugs: