Provider Forms and Documents

General Forms

Behavioral Health

Additional program information coming soon.

Applied Behavior Analysis (ABA) Initial Treatment Request Forms:


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.