Try for free

Pacific Blue Cross Sleep Apnea Pre-Determination Form

Pacific Blue Cross uses this pre-determination form to tell a plan member ahead of time whether a sleep apnea device, such as a CPAP, will be covered under their Extended Health Care plan. The primary physician managing the sleep apnea confirms the diagnosis and prescribed device, and the device provider supplies the sleep study report. Completing the form does not imply approval.

Who completes it

The prescribing physician completes Part 2 (medical information) and certifies being the primary physician managing the patient's sleep apnea. The plan member completes Part 1 and signs the Part 4 consent, and the device provider completes Part 3 with the sleep study report.

Submitting and payment

How to submit it
The completed form goes to Pacific Blue Cross by mail, fax or in-person drop-off, as printed on the form, with the Part 4 consent signed before submission.
Who pays
The patient pays any physician fee for completing the form, and the form states that fee is not eligible for reimbursement under the Pacific Blue Cross Extended Health Care plan.

Good to know

  • The physician certifies having consulted the patient in person; if not, the form asks for an explanation.
  • If the patient is switching devices, such as from CPAP to a mandibular advancement device or another PAP device, Part 2 asks for the medical reason.
  • The provider must attach the sleep study report showing the AHI and, for PAP devices, confirm a 30-day trial and keep the compliance report on file for 5 years.
  • Part 2 also asks about co-morbidities or other conditions to disclose for the eligibility review, and whether this is the patient's first sleep apnea device.

Get the official form

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

Sleep Apnea Device Pre-Determination 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.

See how Vero Documents works

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

Does completing the Pacific Blue Cross sleep apnea form mean the device is approved?

No. The form states that completing it does not imply approval for a sleep apnea device or supplies. Coverage is based on the provisions of the patient's Extended Health Care plan and Pacific Blue Cross qualification criteria, and the pre-determination tells the member ahead of time whether the device will be covered.

Who pays the physician to complete the sleep apnea pre-determination form?

The patient. Pacific Blue Cross states that the patient is responsible for any fees charged by the physician for completing the form, and that these fees are not eligible for reimbursement under the Pacific Blue Cross Extended Health Care plan.

What does the physician certify on the Pacific Blue Cross sleep apnea form?

The physician certifies being the primary physician managing the patient's sleep apnea disorder and having consulted the patient in person, or explains why not. Part 2 also records whether the prescriber is a GP or specialist, the diagnosis, co-morbidities, the type of device prescribed and any previous device.