Health Plans

For medications dispensed by pharmacies, please use the appropriate prescription drug plan prior authorization request form.

Many of our health plans have prior authorization programs for select medications. For medications supplied, billed and administered in a physician's office or outpatient facility, we require prior approval for some medications for all insured groups. We also require prior approval for BlueCross employees and their dependents who we cover with our health plan. (These health plan prior authorization requirements do not apply to State Health Plan or Federal Employee Program members.)

These are the health plan prior authorization forms:

Acthar Gel    Advate    Alphanate    Alphanine    Bebulin    Benefix    Botox    Carimune NF    CytoGam    Euflexxa    Feiba VH NF    Flebogamma    Gamastan    Gammagard Liquid    Gammagard SD    Gammaplex    Gamunex    Helixate    Hizentra    Humate    Hyalgan    Koate    Krystexxa    Monarc-M    Monoclate    Mononine     Novoseven    Octagam    Orencia    Orthovisc    Privigen    Profilinine    Rho (D)    Recombinate    Refacto    Remicade    Rituxan    Sandostatin    Soliris    Stimate    Supartz    Synagis    Synvisc    Synvisc One    Wilate    Tysabri    Xyntha    Xolair