Provider Forms and Documents

General Forms

Behavioral Health

Additional program information coming soon.

Applied Behavior Analysis (ABA) Initial Treatment Request Forms:

Pharmacy

Physicians can access, complete and submit Prior Authorization and Step Therapy request forms electronically from the CoverMyMeds® website:

Pharmacy Drug:

Pharmacy Predetermination Physician Fax Forms:

Prime Specialty Pharmacy Referral:

Predeterminations (formerly called Prior Authorization) and Pre-Authorization/Precertification

Blue Valuesm Total Health Management

THM is an innovative wellness program offered exclusively to BCBSMT group clients and is only available to members of group plans that offer the program as part of their benefit plan. THM uses sound clinical guidelines, specific goals, and effective incentives to help achieve results. Members work with a primary care provider to achieve specific goals.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.