Blue Shield of California Promise Health Plan


REQUEST FOR CAL MEDICONNECT PRESCRIPTION DRUG COVERAGE DETERMINATION

To request an exception (prior authorization) for a medication, please complete the following information. Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.

Cal MediConnect Member Information

Date format: MM/DD/YYYY

* Required Information


Requestor Information

Complete the following section only if the person making this request is not the member or prescriber.

* Required Information


Medication Information

* Required Information


* Reason Why You are Requesting a Coverage Determination

* Required Information


Type of Expedition


H0148_17_033_RX_Accepted


 

 

 

 

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Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association