global request form Form

August 2025

Medicare Plus BlueSM and BCN AdvantageSM Medication Authorization Request Form (for any medication) The most efficient way to request authorization is to use the Medical and Pharmacy Drug PA Portal. To access that portal, log in to availity.com*, click Payer Spaces, click the BCBSM and BCN logo and then click the Medical and Pharmacy Benefit Drug Prior Auth tile.
As an alternative, you can use this form to request authorization for any medical benefit drug that requires authorization for Medicare Plus Blue or BCN Advantage members. Please complete this form and submit via fax to 1-866-392-6465. If you have any questions regarding this process, please contact the Pharmacy Clinical Help Desk at 1-800-437-3803.

PATIENT INFORMATION PHYSICIAN INFORMATION Name Name ID number Specialty Date of birth Male Female Address Diagnosis City/State/ZIP Drug name/HCPCS code Phone: ( )

• Fax: ( )

• Dose and quantity NPI Directions Contact person Date of services Contact person’s phone/ext. Step 1: DISEASE STATE INFORMATION

  1. Is this request for: Initiation
     Continuation Date of last dose: ___
  2. Place of service:
     Home
     Outpatient (NPI ___)
     Office
  3. Height: __ Weight (kg): ___
  4. For Prolia® or Evenity® requests (if applicable):

  Previous bisphosphonate therapy? Name of drug (s)____ Dates: _

  DXA scan T-scores: Left hip: ___ Right hip: ___ Left or right forearm:____ Spine_ 10-year probability of hip fracture ___% Major osteoporosis-related fracture ___% (DXA REPORT MUST BE ATTACHED)

  5. For immune globulin (IVIG) request (if applicable): IgG level_ mg/dL Date:_
  6. For certain asthma drugs (if applicable): IgE level___Date:____ Eosinophil level__Date:_
  7. For retinal medications (if applicable): Which eye is being treated? Left
     Right:
     Both Has the patient tried and failed Avastin®? Yes: Which eye(s)?_ Dates:_
     No
  8. Please provide other relevant history or information for the medication you are requesting:
  9. Attach any chart notes or additional documentation and submit to plan. (Required) Request for expedited review: Please only check this option if the provider believes that waiting for the standard time frame could place the enrollee’s life, health or ability to regain maximum function in serious jeopardy. (CMS definition)

  Physician’s name Physician signature Date Step 2: Checklist Completed form Attached chart notes Concurrent medical problems Prior therapies Step 3: Submit Fax the completed form to 1-866-392-6465.

  *Clicking this link means that you’re leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we’re not responsible for its content. Confidentiality notice: This transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited. If you have received this in error, please notify the sender to arrange for the return of this document.

  Coverage won’t be provided if the prescribing physician’s signature and date aren’t included on this document.