Prior Authorization Forms
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Aetna - Medical Exception/Precertification Request Form for Prescription Medications
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BlueCross - Outpatient Prescription Drug Prior Authorization of Benefits Form, vers. 12/12/2003
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CIGNA - Medication Prior Authorization Form, vers. 04/08/2005
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HealthNet - Pharmacy Prior Authorization Form–Medical Necessity, rev. 06/2005
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Humana - Information Required to Process Drug Authorizations, rev. 09/2001
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Prescription Solutions - Medicare Part D Request Medication Prior Authorization Request Form
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SCVMC - Maximum Daily Dose (MDD) Exceed Request form, rev. 04/2004
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WellCare - Medicare Drug Evaluation Review Form, rev. 12/2005