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Pacific Blue Cross Drug Eligibility Inquiry Form

Pacific Blue Cross Blue Chip plans require prior authorization on certain drugs before they reimburse prescription costs, and this two-page inquiry is how the request is made. The member fills in their details and signs the consent; the physician documents the drug, diagnosis, prior therapies and, for cancer drugs, BC Cancer protocol codes and coverage status. Completing it does not mean approval.

Who completes it

The member completes the black portions, Parts 1 and 2, and signs the consent and declaration; the physician completes the red Parts 3 to 6, giving College ID and specialty, and signs.

Submitting and payment

How to submit it
Mail it, drop it off at Pacific Blue Cross in Burnaby, or fax it; forms that are incomplete or completed by Patient Support Programs are not accepted.
Who pays
The patient pays any physician fee for completing the form, and that fee is not reimbursable under the Pacific Blue Cross Extended Health Care plan.

Good to know

  • Pacific Blue Cross rejects forms completed by Patient Support Programs and incomplete forms, including those without the member's signed Part 2 consent.
  • For cancer drugs, give BC Cancer protocol codes for prior and current therapy, attach the supporting primary article, and attach any BC Cancer denial.
  • Part 5 lists up to five drugs currently or previously prescribed for the condition, with strength, dosage, duration and the reason each was stopped.
  • Part 1 asks for the patient's weight and height with the policy and ID numbers, and Part 4 asks where the drug will be administered.

Get the official form

Download the current version from the source each time; forms change without notice.

Drug Eligibility Inquiry Form

Official pagePDF

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who pays for the Pacific Blue Cross Drug Eligibility Inquiry Form?

The patient. The form states the patient is responsible for any fees the physician charges to complete it, and that those fees are not eligible for reimbursement under the Pacific Blue Cross Extended Health Care plan.

Does submitting the form mean the drug will be covered?

No. The form states that completing it does not imply approval, and coverage is based on the provisions of the member's Extended Health Care plan. Pacific Blue Cross says Blue Chip plans require prior authorization on certain drugs before prescription costs can be reimbursed.

What does Pacific Blue Cross need for a cancer drug request?

Part 4 asks for BC Cancer protocol codes for prior and current therapy, a copy of the primary article supporting the request, and why BC Cancer does not cover the drug: criteria not met or indication not listed (attach the denial), or the drug is not on its benefit list.