Medicare Advantage PPO medical drug policies and forms

Need to treat a Medicare Advantage PPO patient with medical drugs given at a provider office, an outpatient facility location or the patient’s home? You’ll need to submit a prior authorization request and follow our medical policies to avoid a rejected claim. You can quickly submit by logging into Provider Secured Services and by using Novologix®.

If you have access to Provider Secured Services, you’ll also have access to the Medicare Advantage PPO Medical Benefit Medication Prior Authorization link, which allows you to enter a prior authorization request for Medicare Advantage PPO members. If you have access to Provider Secured Services or NovoLogix, you’ll need to submit your request online.

If you don’t have access to Provider Secured Services, you can submit your request for prior authorization by locating the appropriate authorization form below and faxing your request.

Drugs that require prior authorization

You can find which drugs need prior authorization by viewing our Medicare Advantage Medical Drug Prior Authorization and Step Therapy List (PDF). It includes Healthcare Common Procedural Coding System, or HCPCS, codes. It also lists generic and brand names for each drug.

Medical policies

View our medical policies to learn about our drug guidelines.


Medication prior authorization request forms

You can submit a medication prior authorization request through a web tool in Provider Secured Services or by using one of the following:


Looking for a generic medication authorization request form? You can submit a global request form (PDF).