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Providers Request prior authorization

Find forms to request prior authorization for various services for Commercial and Blue Medicare HMO and PPO members.

Commercial request forms for specific services

Behavioral Health Care Length of Stay Extension Authorization Request (PDF) Commercial Adaptive Behavioral Treatment for Autism Spectrum Disorder/Applied Behavioral Analysis (ABA/ABT) Authorization Request (PDF) Eating Disorder Inpatient or Residential Treatment Authorization Request (PDF) Electroconvulsive Therapy (ECT) Authorization Request Form (PDF) Facility Based Crisis Services for Behavioral Health Fax Form (PDF) Inpatient Behavioral Health Care (PDF) Intensive Outpatient Program (IOP) Authorization Request Authorization Request (PDF) Non-Hospital Medical Detox Services for Behavioral Health Fax Form (PDF) Partial Hospitalization Programs (PHP) Authorization Request Form (PDF) Residential Treatment for Behavioral Health Authorization Request Form (PDF) Residential Treatment for Substance Use Disorder Authorization Request (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

Medicare request forms for specific services

Experience Health Electroconvulsive Therapy Authorization Request (PDF) Experience Health Inpatient Psychiatric Care Authorization Form (PDF) Experience Health Psychological and Neurological Testing Authorization Request (PDF) Experience Health Transcranial Magnetic Stimulation Authorization Request (PDF) Medicare Electroconvulsive Therapy (ECT) Prior Authorization Request Form (PDF) Medicare Inpatient Psychiatric Care Prior Authorization Request Form (PDF) Medicare Intensive Outpatient Programs (IOP) Authorization Request (PDF) Medicare Partial Hospitalization Programs (PHP) Authorization Request Form (PDF) Medicare Psychological and Neuropsychological Testing Prior Authorization Request Form (PDF) Medicare Psychotherapy Prior Authorization Request Form (PDF) Medicare Transcranial Magnetic Stimulation (TMS) Prior 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
Bi-level Positive Airway Pressure (BIPAP) for Treatment of Breathing Related Sleep Disorders Prior Authorization (PA) Request Form (PDF) Bi-Level Positive Airway Pressure (BiPAP) for Treatment of Obstructive sleep Apnea Prior Authorization (PA) Request Form (PDF) Continuous Positive Airway Preassure (CPAP) Rental or Purchase Prior Authorization (PA) Request Form (PDF) Durable Medical Equipment Repair or Replacement Prior Authorization Request Form (PDF) Knee Orthosis Prior Authorization Request Form (PDF) Lumbar Sacral Orthosis (LSO)/Thoracic Lumbar Sacral Orthosis (TLSO) Prior Authorization (PA) Request Form (PDF) Oxygen Prior Authorization Request Form (PDF)