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HepatitisCTreatmentPriorAuthorizationRequestForfaster,easierenrollment,enrollonlineorcall(TTY:)MedicalPAlistPDFFile;MApriorauthorizationform PDFFileIMPORTANT:ThisformandfaxnumberareforMedicareAdvantagemembersonly.RequestAuthorizationForms.DownloadIowaMedicalPPDF File;SouthDakotaMedicalNPDFFile;FEP(FederalEmployeeProgram)Medical/SurgicalPriorApprovalFormPPDFFile;BlueDistinction®Centersfor TransplantRadiologyandCardiovascularImagingBehavioralHealth(OutpatientABA)ServiceAuthorizationRequestEnglishMedicarePartBStepTherapy CriteriaGeneralpre-certification/pre-authorizationinformation)Enterthefirstthreecharactersofthemember'sidentificationnumberontheBlueCrossBlueShield IDcard,thenclick"Go"FormcontainsManagemedicalanddrugauthorizationsBariatricSurgeryPrecertificationWorksheetRequestorNameManageyour medicalanddrugauthorizationsAllothersubmissionswillbedestroyedDownloadViewtheauthorizationtable,thensubmitandcheckthestatusof authorizationsintheMedicalPolicyandPre-ServiceReviewforOut-of-AreaMembers*(Thisincludesnotification,pre-certification,pre-authorizationandprior approvalforservicesandPriorAuthorizationForms.SectionIIGeneralInformation.MedicareAdvantagepaperenrollmentform–Print,filloutandmailthis paperapplicationFaxUrgentDeterminewhichradiologyandcardiovascularimagingservicesrequirepriorauthorizationthroughEviCore®Ifneeded,finda non-MedicareAdvantageformDrugauthorizationlistPrefixBlueMedicareAdvantagePPO,EnhancedPPO,andAveraPPOAuthorizationAgreementPDF FileContractingprovidersneedtousetheonlineauthorizationtoolFormcontainsPersonalIdentifiableInformationrelatedtoaSubstanceUseDisorder(SUD) servicesrequestFollowthesesteps)SelectthetypeofinformationbeingrequestedPAFormsforPhysiciansFederalEmployeeProgram(FEP)medical authorizationsMedical/SurgicalPriorApproval(Pre-serviceInquiry)ThisformshouldONLYbeusedbyprovidersthatdonothaveaccesstotheUtilization ManagementTool.HomeHealthPrecertificationTheseformsareonlytobeusedfornon-contractingorout-of-stateproviders.Medicalpolicy.Viewdrug authorizationandquantitylimitstoseewhichdrugsrequiresanpriorauthorizationHospiceInformationforMedicarePartDPlansMedical/SurgicalPrior Approval(Pre-serviceInquiry)ThisformshouldONLYbeusedbyprovidersthatdonothaveaccesstotheUtilizationManagementToolSkilledNursingFacility andInpatientRehabilitationAssessmentFormPDFFilePharmacyFormsReviewType:Non-UrgentYesPhoneWhenaPAisneededforaprescription,the memberwillbeaskedtohavethephysicianorauthorizedagentoftheFaxcompletedformtoByusingthisform,thephysician(orprescriber)isaskingfor Medical/PartBdrugcoveragemeetingoneorbothcriteria:Thedrugisbeingdrugsthatrequireapriorauthorizationaripiprazoleabecmaabrilada(1pen)abrilada (2pen)abrilada(2syringe)abstralacanyaaciphexsprinkleaciphexactemraactemraPriorAuthorizationRequestFormSectionISubmissionEnglishDownload