CVS Caremark's general (global) request for prior authorization or formulary exception for commercial (non-Medicare) prescription benefit plans.
- Completed by
- Prescriber
- Issued by
- CVS Caremark
- Format
- Fillable PDF
- Language
- English
Highmark Prescription Drug Medication Request Form
Highmark Blue Cross Blue Shield uses this general request for prescription drug prior authorization or a step therapy exception when no drug-specific form applies. The multi-region version covers members in western and northeastern Pennsylvania, central and southeastern Pennsylvania, western New York and northeastern New York, and a separate version serves Delaware. A prescriber meets it when a Highmark member's drug needs approval.
Who completes it
The prescriber completes the whole two-page form.
Submitting and payment
- How to submit it
- Highmark's pharmacy forms page states that all prior authorization requests must now be submitted through its provider portal, Availity; the form documents the details the request needs.
Good to know
- Highmark lists its drug-specific forms in one alphabetical list tagged by region; use one of those when it exists for the drug.
- Highmark removed West Virginia prior authorization forms because Senate Bill 267 requires electronic submission of prior authorization requests from July 1, 2024.
- Specialty drugs have their own requests, including the Specialty Drug Request Form (MM-060) and a Medical Specialty Drug Prior Authorization Request Form.
- Delaware members have a separate Delaware version of the request, listed on the same Highmark pharmacy prior authorization forms page.
Get the official form
Download the current version from the source each time; forms change without notice.
Prescription Drug Medication Request Form
Fill it with Vero
If your copy of the form is a fillable PDF, upload it 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.
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 and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Which Highmark regions use the multi-region medication request form?
Highmark lists it for western and northeastern Pennsylvania, central and southeastern Pennsylvania, western New York and northeastern New York. Delaware has its own version, and West Virginia paper prior authorization forms were removed because state law requires electronic submission.
Can I fax the Highmark prescription drug request form?
Highmark's pharmacy prior authorization forms page states that all prior authorization requests must now be submitted through its provider portal, Availity. The form remains posted, so it can be used to gather the drug, diagnosis and history details before entering the electronic request.