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Policies & Guidelines
- Advanced Imaging
- Behavioral Health
- Chronic Condition Management
- Genetic Testing
- Hemophilia Drugs
- Medical Oncology Regimen Program
- Medical Policies
- Pre-Service Review (Precertification/Predetermination)
- Provider-Administered Drug Policies
- Radiation Therapy
- Self-Administered Drug Policies
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Self-Administered Drug Prior Authorization Forms
Drug policies are based on:
- information in FDA-approved package inserts (and black box warnings, alerts or other information disseminated by the FDA, as applicable);
- research of current medical and pharmacy literature; and/or,
- review of common medical practices in the treatment and diagnosis of disease.
Note: Coverage is subject to the member's specific benefits. Group-specific benefits will supersede these policies when applicable. Always check eligibility and benefits through your local Blue Plan provider portal or your practice management system to confirm member-specific benefits.
Forms
Click on the appropriate link below to print the form to request prior authorization for these drugs: