• Group and Individual Products (Regence HSA Healthplan 2.0^SM, Innova^®, Engage^®, Activate^SM, BlueChoices, Blue Selections, and Blue Solution)
• Medicare Products (Regence MedAdvantage and Medicare Part D Prescription Drug Plans)
• Federal Employee Program (FEP)
• Regence Rx

Pre-authorization Request Form (PDF) for medical, surgical or DME services

Pre-authorization Information Form (PDF) for home health and ancillary therapies

This form is used when a condition requires a pre-authorization. A limited number of services require a pre-authorization.

• Indicate which product the member has.
• Indicate if this is the original request.
• Complete part II of the form, including all procedures/HCPCS codes AND diagnosis.
• If supporting documentation is attached, mail the form to the address listed.
• If no supporting documentation, fax the form to the number(s) indicated on form.

Statement of Medical Necessity for Oncotype DX (PDF)

This form is used to facilitate medical necessity for Oncotype Dx^® Breast Cancer Assay. Codes include S3854 and 84999.