The Premera prior authorization form comes in two versions: Form 014787 for medical services and Form 026810 for pharmacy requests. Both are available on the Premera provider site and through the Availity portal. The form itself is straightforward; what determines approval is matching the right form to the request, filling every field with identifiers that match the member’s card, and attaching clinical documentation that speaks to Premera’s medical necessity criteria.
Pick the Right Form (and the Right Reviewer)
Form 014787 (updated February 2026) covers medical services, procedures, inpatient admissions, DME, home health, and dental. Form 026810 (updated March 2026) covers medications, formulary exceptions, step therapy overrides, and quantity limit exceptions.
Not every service that needs prior authorization goes to Premera directly. Advanced imaging (CT, MRI, MRA, PET, echocardiography, nuclear cardiology), genetic testing, radiation oncology, and sleep studies are reviewed by Carelon Medical Benefits Management through its own portal and phone line.1Premera Blue Cross. Carelon Medical Benefits Management Submitting these on the Premera form sends them to the wrong reviewer and wastes days.
Confirm the Service Requires Authorization
Premera publishes a code list (document 050237, current version dated June 2026) that identifies every CPT and HCPCS code requiring advance approval. Download it from the Premera provider library or check the code through Availity before you start the form. If a service is performed without an approved authorization when one was required, Premera’s form language states the charges will either be denied outright or have a financial penalty applied to the claim.2Premera Blue Cross. Premera Blue Cross Prior Authorization Code List
Completing the Medical Form (014787)
The medical form has six sections. Skipping a field or entering the wrong identifier bounces the request back without a decision.
Section A: Member and Patient Information
Enter the patient’s full name as printed on the Premera card, date of birth, and the member ID in three parts: the alpha prefix (letters before the numeric string), the ID number, and any suffix. These identifiers tie the request to the member’s benefit plan. A wrong prefix or missing suffix means Premera’s system cannot match the request to the account.
Section B: Urgent Request Designation
Check this box only if delay could seriously jeopardize the patient’s life or health. The treating physician signs the attestation and adds printed name, title, and date. Do not use this designation for routine or elective procedures. Premera will reclassify it under standard timelines, and repeated misuse of the urgent flag can draw scrutiny.
Section C: Provider Information
Fill in two sets of provider details: the requesting provider and the servicing provider. Each needs name, contact person, full office address, phone, fax, Tax ID, and NPI. If both are the same, check “Yes” and skip the second set. The fax number here is where Premera sends the approval or denial letter, so verify it before submitting.3Premera Blue Cross. Pre-service/Prior Authorization Review Request
Section D: Substance Use Disorder Notice
No fields to complete. The section is a regulatory notice about 42 CFR Part 2 confidentiality protections.
Section E: Facility Information
Select the facility type: outpatient hospital, inpatient hospital, ambulatory surgical center, freestanding infusion center, home, office, or other. The form then asks whether the provider has privileges at an ASC within 30 miles. If you are requesting outpatient hospital instead of an ASC, check at least one exception reason: necessary equipment unavailable at an ASC, patient under 18, clinical guidelines prohibit ASC use due to a health condition or BMI of 50 or higher, or additional services require a hospital outpatient department. Add the facility’s name, contact, address, phone, fax, TIN, and NPI.3Premera Blue Cross. Pre-service/Prior Authorization Review Request
Section F: Clinical Information
Enter the scheduled date of service, any existing reference or authorization number (for modifications), the CPT or HCPCS procedure code, any applicable modifiers (left/right, new/rental), units, and the ICD-10 diagnosis code supporting medical need. Every code must match what you intend to bill. A mismatch between the authorization and the eventual claim is one of the most common reasons for post-service denials.
Completing the Pharmacy Form (026810)
The pharmacy form focuses on formulary coverage and drug-specific rationale rather than facility details.
Section A collects the member’s name, ID, date of birth, phone, and physical address (no PO boxes). Section B captures the prescriber’s name, phone, fax, address, NPI, signature, and date. Section C asks for the medication name and strength, ICD-10 diagnosis, quantity, whether this is new or ongoing therapy (with start date), expected length of therapy, and drug allergies.4Premera Blue Cross. Pharmacy Prior Authorization and Exception Request
Section D is a single checkbox certifying medical necessity for brand-name contraceptives. Section E is the expedited review request; check it and have the prescriber sign if the standard 72-hour review window could seriously jeopardize the patient’s health. Section F identifies the exception type: non-formulary drug coverage, step therapy override, quantity limit exception, or off-label use.
Section G is where most pharmacy denials are won or lost. You select the clinical rationale: the patient tried alternative drugs that failed or caused adverse effects, the patient is stable on the current medication and switching poses high risk, the patient needs a different or higher dosage, or off-label use is supported by medical compendia or scientific evidence. “Other” requires a written explanation. Be specific. “Patient failed prior therapy” is less persuasive than naming the drugs tried, the duration, and the documented outcome.
Clinical Documentation That Decides the Outcome
The form is a shell. Reviewers rely on the attached records to judge medical necessity.
Attach office visit notes where the service was ordered, progress notes documenting the patient’s condition and treatment history, lab results or imaging reports supporting the diagnosis, and specialist consultation notes. For DME, include the written order or prescription. For physical therapy or rehabilitation, include a signed plan of care.5Centers for Medicare & Medicaid Services. Complying with Medical Record Documentation Requirements
Records must be legible and signed. If the signature is illegible, include a signature log. Missing signatures on orders and incomplete clinical notes are among the most frequent documentation errors behind denials, and all of them are preventable.
How to Submit
Availity for Medical Services
Availity Essentials is Premera’s primary electronic submission portal. Register at availity.com/premera if your office doesn’t already have an account. Sign in, go to Patient Registration, then Authorizations and Referrals. Select Authorization Request, choose a Premera plan as the payer, and complete the fields. Electronic submission generates a confirmation and lets you track status. Availity Client Services handles technical issues at 800-282-4548, Monday through Friday, 8 a.m. to 8 p.m. Eastern.6Premera Blue Cross. Provider Training Availity
Carelon for Imaging and Specialty Services
Advanced imaging, genetic testing, radiation oncology, and sleep medicine route through Carelon. Register at Carelon’s provider portal and submit online, or call 866-666-0776.1Premera Blue Cross. Carelon Medical Benefits Management
Pharmacy Submissions
Submit medication requests electronically through CoverMyMeds or ExpressPAth, which integrate with most EHR systems. You can also use Premera’s Rx search tool to generate a partially completed fax form specific to the drug, or fax the completed pharmacy form directly. The medical necessity fax number for medications is 888-260-9836. The Pharmacy Services Center is at 888-261-1756.7Premera Blue Cross. Drugs Requiring Approval
Fax and Specialty Channels
To modify an existing prior authorization by fax, use 800-843-1114. Dental prior authorizations go to 425-918-5956. Federal Employee Program members have a dedicated prior authorization fax at 866-948-8823, with a mailing address of Premera Blue Cross – FEP, PO Box 33932, Seattle, WA 98133.8Premera Blue Cross. Prior Authorization for Non-Individual Plan Members
Mail is the slowest option because intake is manual. If you fax, keep the transmission confirmation page as proof of timely submission.
When to Expect a Decision
Washington state law sets the timelines for managed care plans. Electronic submissions get a decision within three calendar days for standard requests and one calendar day for expedited. Fax or mail submissions get five calendar days for standard and two for expedited. If Premera needs more information, it must request it within one calendar day for electronic submissions or five for nonelectronic.9Washington State Legislature. Washington Code RCW 74.09.840
Pharmacy requests run on their own schedule. Standard drug reviews take up to five calendar days, urgent drug reviews are decided within 48 hours. Formulary and pharmacy exception requests have tighter windows: 72 hours for standard and 24 hours for urgent.7Premera Blue Cross. Drugs Requiring Approval
Starting in 2026, the CMS Interoperability and Prior Authorization Final Rule requires impacted payers to issue decisions within 72 hours for urgent requests and seven calendar days for standard requests.10Centers for Medicare & Medicaid Services. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F
After the Decision
Approved
An approved authorization comes with a reference number that must be included on the claim. The approval is valid for 180 days from the issue date. Some medications have different approval windows, so check the specific expiration date on the approval letter. If the authorization expires before the service is performed, submit a new request.11Premera Blue Cross. Extending Length of Approval for Prior Authorizations
Pending
“Pending” means Premera needs additional clinical information. The review clock pauses while the insurer waits, so respond quickly. The notification will specify what records or clarification are needed.
Denied
Denial letters must include a specific reason and reference the clinical criteria used.12Centers for Medicare & Medicaid Services. CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process Read it before you do anything else. It tells you which criteria the request failed to meet and what additional information Premera wants. Compare the patient’s records against those criteria to find what was missing or overlooked.
Peer-to-Peer Review
Before filing a formal appeal, request a peer-to-peer review. The treating physician discusses the clinical rationale directly with a Premera medical director. The denial letter has instructions for requesting one; for individual plan members, the number is 800-607-0546. Peer-to-peer is available only for medical necessity disagreements, not administrative denials such as non-covered services or member ineligibility.
Level 1 Appeal
If peer-to-peer doesn’t resolve it, submit a Level 1 appeal with supporting documentation addressing the specific criteria cited. An appeals representative reviews the submission. If the Level 1 appeal is denied, the member receives a letter explaining the reason, who reviewed it, and the next steps.13Premera Blue Cross. Understanding the Level 1 Appeals Process
External Review
After internal appeals are exhausted, members can request an external review by an independent review organization. The IRO has no financial relationship to Premera, and its physicians evaluate medical necessity from scratch. The process and timelines depend on plan type and state of residence; the appeal decision notice includes instructions for initiating external review.