Pre-authorization Information

Medical Pre-authorization Lists

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

Pre-authorization forms
Pre-authorization Request Form (PDF)	This form may be used to facilitate the pre-authorization process for medical, surgical or DME services.
Pre-authorization Information Form (PDF)	This form may be used to facilitate the pre-authorization process for home health and ancillary therapies.
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. Fax completed forms to 1 (800) 453-4341


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