Request prior authorization

Adaptive Behavioral Treatment for Autism Spectrum Disorder/Applied Behavioral Analysis (ABA/ABT) Authorization Request (PDF)

Behavioral Health Care Length Of Stay Extension Authorization Request Form (PDF)

Commercial Electroconvulsive Therapy Fax Form (PDF)

Commercial Residential Treatment Behavioral Health Form (PDF)

Commercial Residential Treatment Substance Use Disorder Fax Form (PDF)

Eating Disorder Inpatient Or Residential Treatment Authorization Request Form (PDF)

Inpatient Behavioral Health Care (PDF)

Intensive Outpatient Program (IOP) Authorization Request Authorization Request (PDF)

Non-Hospital Medical Detox Services for Behavioral Health (PDF)

Partial Hospitalization Programs (PHP) Authorization Request Form (PDF)

Transcranial Magnetic Stimulation (TMS) Authorization Request (PDF)

Drugs that require prior authorization are listed on the Prescription Drugs page. Use the prior authorization drug search tool to find the drug and to see its coverage criteria and prior authorization forms for each formulary.

Commercial Prior Authorization Drug Search

Rehabilitation Program Prior Authorization Request (Log In to Blue e)

Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), and Long Term Acute Care Hospital (LTACH) Treatment Plan Update Authorization Request Form (PDF)

Facet Joint Denervation Authorization Request Form (PDF)

Intensity Modulated Radiation Therapy (IMRT) Authorization Request Form (PDF)

Laparoscopic Radiofrequency Ablation (RFA) of Uterine Fibroids: Acessa™ Authorization Request Form (PDF)

Musculoskeletal Program Authorization Request (Log In to Blue e)

Prostatic Urethral Lift Authorization Request Form (PDF)

Topical Negative Pressure Therapy for Wounds Authorization Request Form (PDF)

Topical Negative Pressure Therapy for Wounds Extension Authorization Request Form (PDF)

Trigger Point and Tender Point Injections Prior Review Request for Services Form (PDF)

General Precertification Request Form (D-SNP) (PDF)

Overpayment Refund Notification Form (D-SNP) (PDF)

Recoupment Authorization Form (D-SNP) (PDF)

Medicare Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)

Medicare Inpatient Psychiatric Care Authorization Request Form (PDF)

Medicare Intensive Outpatient Programs (IOP) Authorization Request Form (PDF)

Medicare Partial Hospitalization Programs (PHP) Authorization Request Form (PDF)

Medicare Psychological and Neuropsychological Testing Authorization Form (PDF)

Medicare Psychotherapy Authorization Request Form (PDF)

Medicare Transcranial Magnetic Stimulation (TMS) Authorization Request Form (PDF)

Drugs that require prior authorization are listed on the Prescription Drugs page. Use the prior authorization drug search tool to find the drug and to see its coverage criteria and prior authorization forms for each formulary.

Medicare Prior Authorization Drug Search

Medicare BiPAP for Treatment of Breathing Related Sleep Disorders Prior Authorization Request Form (PDF)

Medicare BiPAP for Treatment of Obstructive Sleep Apnea Fax Form (PDF)

Medicare Continuous Positive Airway Pressure Rental or Purchase Request Fax Form (PDF)

Medicare Durable Medical Equipment Repair or Replacement Request Fax Form (PDF)

Medicare Knee Orthosis Prior Authorization Request Form (PDF)

Medicare Lumbar Sacral Orthosis (LSO)/Thoracic Lumbar Sacral Orthosis (TLSO) Prior Authorization (PA) Request Form (PDF)

Medicare Oxygen Prior Authorization (PA) Request Form (PDF)