Download Rx Prior Authorization form

RX PRIOR AUTHORIZATION FORM2
 BlueCare® Traditional
 BlueCare HMO Plus
 BlueCare PPO (ACII)
 BlueCare Major Medical
THIS FORM WILL BE RETURNED IF THE APPROPRIATE
INFORMATION IS NOT COMPLETED AND/OR NOT LEGIBLE.
THIS FORM MAY BE FAXED TO US AT 866-754-0370.
Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing materially false
information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
Section I. Patient Information
PATIENT’S NAME (LAST, FIRST, M.I.)
ID NUMBER
ADDRESS
CITY
STATE
ZIP
DATE OF BIRTH
RELATIONSHIP TO CARD HOLDER
 CARD HOLDER
 SPOUSE
 CHILD
Section II. To be completed by Prescribing Physician (Type or print)
PHYSICIAN NPI #
PHYSICIAN’S NAME (LAST, FIRST, M.I.)
MD, DO, ETC.
ADDRESS
STATE
SPECIALTY
CITY
ZIP
PHONE
PRESCRIBED DRUG
FAX
STRENGTH
DAILY DOSAGE
LENGTH OF THERAPY
PRIMARY DIAGNOSIS
 STEP THERAPY
 OTHER
(If samples were given by the physician on any alternative drugs used, please attach office notes documenting failure and/or intolerance)
ALTERNATIVE DRUG(S) USED
DATE(S) USED
TREATMENT FAILURE
 YES  NO
IF YES, PLEASE GIVE REASON
ADVERSE REACTION
 YES  NO
IF YES, PLEASE GIVE REASON

QUANTITY LIMITS (ex. Amerge, Imitrex, etc.) Please indicate medical justification for exceeding quantity dosing limits.

MANAGED QUANTITY DOSES (ex. when prescribing 10 mg twice daily instead of 20 mg once daily).
Please attach office notes documenting treatment failure and/or intolerance to once daily dosing.
 WEIGHT LOSS DRUGS ONLY Please Note: The patient’s benefit must cover weight loss, the physician must monitor the patient every three (3) months
while the member is taking this medication. These medications will be approved for a maximum of one year at three (3) month intervals based on the patient's
body mass index. (Form must be received within two weeks from date of visit.)
DATE OF MOST RECENT VISIT

HEIGHT
WEIGHT
IF ALREADY
TAKING
WEIGHT LOSS
MEDICATION:
DATE OF
PREVIOUS VISIT
WEIGHT LOSS IN
LAST 3 MONTHS
TOTAL WEIGHT
LOSS
SYNAGIS PLEASE NOTE GESTATIONAL AGE OF CHILD
Continued on next page. Both pages must be completed appropriately and submitted for review. 1 of 2
Please Note: Do not mail this form if you have already faxed it to us.
BCNEPA Use Only
NCD#
DATE
INITIALS
APPROVEDI Patient
DENIED
PA#
RX PRIOR AUTHORIZATION FORM2
PATIENT’S NAME
ID NUMBER
(This section along with Sections I and II must be completed in full by the pharmacist.).
 COMPOUND DRUGS
AMOUNT
MAIN NDC #
OTHER ING.
DATE
PHARMACY NCPDP #
PHARMACY NAME
PHONE
FAX
CONTACT
 ACTOS
RECENT SERUM CREATININE
DOES PATIENT HAVE CHF
DATE
 YES
 AVANDIA
 AVANDAMENT
RECENT HgbA1C LEVEL
DATE
 NO
WHICH OF THE FOLLOWING HAS THE PATIENT EXPERIENCED
 YES
 NO
Failed Glucophage (three month trial) in a dose in excess of 1,500 mg/day and requires < 2.0% reduction in HgbA1C
 YES
 NO
Been diagnosed with renal insufficiency or heart failure and has failed a Sulfonylurea (three month trial) at a maximum dosage and
requires < 2.0% reduction in HgbA1C
 YES
 NO
Tried Glugophage and failed because of side effects and requires < 2.0% reduction in HgbA1C
Please provide any additional information to support coverage of Avandis/Actos
PLEASE CHECK THE APPROPRIATE BOX FOR THE DIAGNOSIS AND ANTI-FUNGAL YOU ARE PRESCRIBING
 DIFLUCAN Prior authorization is required ONLY if
prescribing more than one 150mg tablet in a 30-day period. All
other strengths require prior authorization if amount exceeds
20 within a 30-day period.
STRENGTH
TABS/DAY
 LAMISIL
STRENGTH
LENGTH OF THERAPY
X
 ORAL THRUSH
 TINEA CORPORIS
 SPORANOX
WHAT AREA OF THE BODY
 ONYCHOMYCOSIS Our criteria require that this diagnosis be confirmed by positive
test results of one of the following: DTM, KOH, or PAS, and in addition, office notes
documenting medical necessity. Please include copies with prior authorization form. If
this information is not included, the prior authorization will be denied.
 IS THE PATIENT IMMUNOCOMPROMISED
 YES  NO
 ESOPHOGEAL CANDIDIASIS
 IS THE PATIENT DIABETIC
 YES
 NO
 VAGINAL CANDIDA
 OTHER COMPLICATIONS
 YES
 NO
 PROPHYLAXIS
FOR WHAT CONDITION
PLEASE SPECIFY
 OTHER
LIST ANY MEDICATIONS USEED TO TREAT CONDITION
 OTHER (Anabolic Steroids, Injectible Fertility Drugs, Growth Hormones, Lupron, Oral Contraceptives, Retin A, etc.)
Medical justification for taking medication
I hereby certify that the above information is correct.
Physician’s signature __________________________________________________
Date ___________________
Pharmacist’s signature (for Compound Drugs only) ____________________________________________________
BCNEPARXPA 8/08