Prior Authorization Forms
Prior Authorization and Exception Request Forms:
- General Exception Request Form (Self Administered Drugs)Open a PDF
- Medicare D End Stage Renal Disease - Request for Drug EvaluationOpen a PDF
- Medicare D Hospice - Request for Drug EvaluationOpen a PDF
- Medicare D Lidocaine Patch & Flector Patch - Request for Drug EvaluationOpen a PDF
- Medicare D Opioid Prior Authorization Form - Request for Drug & Morphine Milligram Equivalents ReviewOpen a PDF
Excellus BlueCross BlueShield is an HMO/PPO/HMO D-SNP plan with a Medicare contract and a contract with the New York State Medicaid program. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_10519_C.
This page last updated 10-01-2024.
