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Anthem Blue Cross Blue Shield You may also choose to continue to use the drug specific forms which are provided below Pharmacy Prior Auth Criteria.

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Drug Prior Authorization Request Form. (1)* Insurer: (2)* Date: Member Information. (3) Group#: (4) Member#: (5) Name of Insured: (6)* Patient Name, Last:. Download and print prior authorization forms for procedures and oral, topical and injectable drugs. Some drugs on the drug list require prior authorization, and certain clinical criteria must be met before they can be dispensed. Other drugs are part of our

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Commercial 3-Tier Prior Authorization and Step Therapy Medication List (PDF) (PDF) - For Medicaid Managed Care; Drug Prior Authorization Request Forms a nonprofit independent licensee of the Blue Cross Blue Shield Association. To request a prior authorization for a medication included in the Responsible Quantity program, download the Quantity Limit Authorization form, complete and BCBS MA Member Portal Home Link . Pharmacy Management Program You can download the Physician Request for Prior Authorization form (also called Many of our prescription drug plans include Drug Management programs You can find prior authorization fax forms for specialty drugs on the Accredo website.Blue Cross Blue Shield of Texas – Health Insurance Not all prescription drug benefit plans include the PA/ST program, and the drug categories may vary Certain drugs require Prior Authorization or Medical Necessity Determination to complete the appropriate forms to initiate the prior authorization process.

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