Prior authorization forms and templates

Download and print the most commonly requested prior authorization fax forms for procedures, physician administered drugs and pharmacy outpatient drugs, choosing from the lists below.. Also available below are templates to be used for authorization notices to Blue Shield TotalDual (HMO D-SNP) and Inspire (HMO D-SNP) members.

Blue Shield of California Promise Health Plan

Blue Shield Medicare

Blue Shield TotalDual (HMO D-SNP) or Blue Shield Inspire (HMO D-SNP)

Templates for authorization-related notices ​​ The templates and non-disclosure attachments, available below to download, are to be used as appropriate for notifying Blue Shield TotalDual (HMO D-SNP) or Blue Shield Inspire (HMO D-SNP) plan members regarding authorization determinations. All of these notices must be accompanied by the non-disclosure attachments, also available below to download, in the preferred language of the member. Template for all carveout notice (PDF, 56 KB) Template for all detailed explanation of non-coverage (updated) (PDF, 66 KB) Template for all detailed notice of discharge (updated) (PDF, 67 KB) Template for all expedited criteria do not meet (PDF, 64 KB) Template for all notice of dismissal of coverage (updated) (PDF, 60 KB) Template for all notice of Medicare non-coverage (PDF, 68 KB) Template for all service approval (PDF, 68 KB) Template for denial notice (PDF, 108 KB) Template for DSNP CDLI denial (PDF, 119 KB) Template for fast complaint letter (PDF, 105 KB) Non-disclosure attachments to include with all notices sent to members​ You can download and use the non-disclosure attachment in the member’s preferred language, to include with any notice you send to the member. The notices are available in Arabic, Armenian, Chinese, English, Farsi, Hmong, Khmer, Korean, Spanish, Tagalog, and Vietnamese.​ Arabic non-disclosure attachment​ (PDF, 115 KB) Armenian non-disclosure attachment​ (PDF, 78 KB) Chinese (traditional) non-disclosure attachment​ (PDF, 95 KB) English non-disclosure attachment​ (PDF, 597 KB) Farsi non-disclosure attachment​ (PDF, 100 KB) Hmong non-disclosure attachment​ (PDF, 58 KB) Khmer non-disclosure attachment​ (PDF, 136 KB) Korean non-disclosure attachment​ (PDF, 79 KB) Spanish non-disclosure attachment​ (PDF, 79 KB) Tagalog non-disclosure attachment​ (PDF, 40 KB) Vietnamese non-disclosure attachment (PDF, 133 KB)

Prescription drug prior authorization and step therapy exception request forms for Commercial members

Procedure authorization request forms

Commercial procedures/HCPCS

• Form Name
• Advanced Imaging
• Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
• Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
• Bariatric Surgery
• Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)
• Clinical Trials (for any indication)
• Continuous Glucose Monitoring
• Dental Anesthesia
• Elective Invasive Coronary Angiography (ICA)
• Elective Percutaneous Coronary Intervention (PCI)
• Gender Affirmation Surgery
• General Request-Urgent Request-Standing Referral
• Genetic Testing: Cardiac Disorders
• Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders
• Genetic Testing: Hereditary Cancer Susceptibility
• Home Health Care
• Hysterectomy Surgery for Benign Conditions
• Implantable Cardioverter Defibrillators
• Intensity-Modulated Radiotherapy of the Breast and Lung - Post Service Fax Form
• Intensity-Modulated Radiotherapy of the Breast and Lung - Prior Authorization Fax Form
• Intensity-Modulated Radiotherapy: Abdomen and Pelvis - Post Service Fax Form
• Intensity-Modulated Radiotherapy: Abdomen and Pelvis - Prior Authorization Fax Form
• Intensity-Modulated Radiotherapy: Central Nervous System Tumors - Post Service Fax Form
• Intensity-Modulated Radiotherapy: Central Nervous System Tumors - Prior Authorization Fax Form
• Knee Arthroplasty for Adults
• Orthognathic Surgery
• Physical Therapy- Applies to eBay only
• Radiation Oncology – Post Service Fax Form
• Radiation Oncology – Prior Authorization Fax Form
• Reconstructive Breast Surgery/Management of Breast Implants
• Reconstructive Services
• Reduction Mammaplasty for Breast-Related Symptoms
• Spine and Pain Management
• Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
• Total Artificial Hearts and Implantable Ventricular Assist Devices
• Treatment of Varicose Veins/Venous Insufficiency

Procedures for Federal Employee Program members

• FEP Form Name
• ABA Therapy
• Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
• Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
• Avastin
• Avsola
• Balloon Ostial Dilation for Treatment of Chronic Sinusitis
• Bariatric Surgery
• Beovu Eylea Vabysmo
• Bio-Engineered Skin and Soft Tissue Substitutes
• Byooviz Cimerli Lucentis
• Cochlear implant
• Diagnosis of Obstructive Sleep Apnea Syndrome
• Epogen Procrit
• Extension of Benefits
• Gender Affirmation Surgery (facial)
• Gender Affirmation Surgery (non-facial)
• General Request
• Givlaari
• Guardant
• Hearing Aids
• Herceptin
• Herceptin Hylecta
• Infliximab Avsola Inflectra Renflexis
• Inpatient Residential Treatment
• Kanjinti Ogivri Ontruzant
• Laboratory Panel
• Medical Injectable Drug
• Medical Management of Obstructive Sleep Apnea Syndrome
• Mvasi Zirabev Bevacizumab
• Neulasta Onpro
• Neupogen
• Nivestym Granix Releuko Zarxio
• Ocrevus
• Onpattro
• Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
• Oxlumo
• PET Scan-Oncologic Applications
• Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
• Remicade
• Renflexis
• Retacrit
• Riabni-Ruxience-Truxima
• Rituxan
• Rituxan Hycela
• Rolvedon
• Simponi
• Skilled Nursing (SNF)
• Skyrizi
• Soliris
• Stelara
• Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
• Tegsedi
• Temporomandibular Joint Disorder
• Transcranial Magnetic Stimulation
• Udenyca Fulphila Nyvepria Ziextenzo
• Ultomiris
• Virtual Colonoscopy/Computed Tomography Colonography
• Vyvgart

Prior authorization lists

View the list of medical services and procedures requiring medical necessity review and/or supplemental documentation before payment is made.

Prior authorization requirements for out-of-area Blue plan members

Find medical policy and general prior authorization requirements for your patients who are covered by an out-of-area Blue Plan.