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Pharmacy Prior Authorization Forms

  • Addyi Prior Authorization Form
  • Blood Disorders Medication Request Form
  • CGRP Inhibitors Medication Request Form
  • Chronic Inflammatory Diseases Medication Request Form
  • Diabetic Testing Supply Request Form
  • Dificid Prior Authorization Form
  • Dupixent Prior Authorization Form
  • Extended Release Opioid Prior Authorization Form
  • Medicare Part D Hospice Prior Authorization Information
  • Modafinil and Armodafinil PA Form
  • PCSK9 Inhibitor Prior Authorization Form
  • Request for Non-Formulary Drug Coverage
  • Short-Acting Opioid Prior Authorization Form
  • Specialty Drug Request Form
  • Sunosi Prior Authorization Form
  • Testosterone Product Prior Authorization Form
  • Transplant Rejection Prophylaxis Medications
  • Vyleesi Prior Authorization Form
  • Weight Loss Medication Request Form
Last updated on 10/24/2022 10:44:11 AM

 

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Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.

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