Drugs Covered Under the Medical Benefit: Medication Authorization Request Forms
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Use the appropriate Medication Authorization Request Form below to request prior authorization for a medication that's covered under a member's medical benefits and administered in an outpatient location. |
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*This drug doesn’t currently require prior authorization. Use this form only when requesting retroactive authorization. |
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For medications that do not have a specific Medication Authorization Request form listed, use this general form. |
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| Medicare Plus Blue℠ and BCN Advantage℠ Forms | |
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Go to the How Do I Submit a Drug Prior Authorization Request for Medicare Plus Blue PPO and BCN Advantage? page on bcbsm.com. |
| Blue Cross and Blue Shield Federal Employee Program® Forms | |
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Use these forms to obtain prior authorization for administering medications in physician's offices and outpatient hospitals, including urgent care, hospital-based infusion care centers, and clinics where the drug is injected or infused and billed on a UB04 or CMS 1500 form. |
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