Page Title, Social Icons for page template
Prior Authorization Forms
EXC-MDP-MDM- Prior Authorization Forms - Information for Prescription Drugs
Prior Authorization and Exception Request Forms:
- General Exception Request Form (Self Administered Drugs)Open a PDF
- Quantity Limit Exception FormOpen 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
- Medicare D Sulfonylurea - Request for Drug EvaluationOpen a PDF
EXC-CMS Footer
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 www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_5994_C.
This page last updated 10-01-2019.
