Prior Authorization Forms

  • Prior Authorization and Exception Request Forms:
  • General Exception Request Form (Self Administered Drugs)
  • Quantity Limit Exception Form
  • Medicare D End Stage Renal Disease - Request for Drug Evaluation
  • Medicare D Hospice - Request for Drug Evaluation
  • Medicare D Lidocaine Patch & Flector Patch - Request for Drug Evaluation
  • Medicare D Opioid Prior Authorization Form - Request for Drug & Morphine Milligram Equivalents Review
  • Medicare D Sulfonylurea - Request for Drug Evaluation
Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at or learn about filing a complaint by contacting the Medicare Ombudsman. .
This page last updated .