Medicare Advantage PPO medical drug policies and forms

Need to treat a Medicare Advantage PPO patient with medical drugs given at a provider office or outpatient facility location billed as a professional claim*? You'll need to submit a prior authorization request and follow our medical policies to avoid a rejected claim. You can quickly submit your request through a web tool called NovoLogix® within Provider Secured Services.

If you already have access to Provider Secured Services, fax an Addendum P Form (PDF) to gain access to the web tool. It offers real-time status checks and immediate approvals for certain medications.

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.

*Authorization isn’t required for these medications when they are submitted on a facility claim form (such as the UB 04) or electronically via 837I transaction.

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).