Prior authorization forms
- Aetna - Medical Exception/Precertification Request Form for Prescription Medications (pdf)
- Anthem - Prior Authorization Request Form, rev. 08/02 (pdf)
- BlueCross - Outpatient Prescription Drug Prior Authorization of Benefits Form, vers. 12/12/03 (pdf)
- CIGNA - Medication Prior Authorization Form, vers. 04/08/05 (pdf)
- HealthNet - Pharmacy Prior Authorization Form–Medical Necessity, rev. 06/05 (pdf)
- Humana - Information Required to Process Drug Authorizations, rev. 09/01 (pdf)
- Prescription Solutions - Medicare Part D Request Medication Prior Authorization Request Form (pdf)
- Santa Clara Family Health Plan - Cal MediConnect Medicare Part D Coverage Determination Request Form, rev. 11/12 (pdf)
- Santa Clara Family Health Plan - Medi-Cal Prescription Drug Prior Authorization Request Form, 08/13 (pdf)
- SCVHHS Non-Formulary Drug Request (NFDR) Form, 08/13 (pdf)
- SCVMC - Maximum Daily Dose (MDD) Exceed Request form, rev. 04/04 (pdf)
- Sierra RX - Exception Request Form (pdf)
- WellCare - Medicare Drug Evaluation Review Form, rev. 12/05 (pdf)