Prescription drug prior authorization request form blue shield. All fields indicated with an asterisk (*) are required for submission. You can start the process by providing the following required information. Submit a separate form for each medication. PRESCRIPTION DRUG MEDICATION REQUEST FORM FAX TO 1-866-240-8123 Fax each form separately. Print, type or write legibly in blue or black ink. Just click on a form to download it. See reverse side for additional details NS_12_0133 Once a clinical decision has been made, a decision letter will be mailed to the patient and physician. This form will be updated periodically and the form number and most recent revision date are displayed in the top left-hand corner. Please contact the member’s pharmacy. * Note: The drugs that have an asterisk no longer require prior authorization. chart notes or lab data, to support the prior authorization or step therapy exception request. NOTE: The prescribing physician (PCP or Specialist) should, in most cases, complete the form. Page 1 of 2 FEP PPO PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM Plan/Medical Group Name: Blue Shield of California ime on all Prior Authorization Requests according to the Blue Cross Blue Shield Service Benefit Plan. Allow us at least 24 hours to review this request. Prior authorization is the requirement that a physician or other qualified provider obtain approval from Blue Shield before prescribing a specific medication, procedure and/or service. standard form, FIS 2288, is being made available by the Department of Insurance and Financial Services to simplify exchanges of information between prescribers and health insurers as part of the process of requesting prescription drug prior authorization. Please use a separate form for each drug. Failure to complete this form in its entirety may resu Please see the Prescription drug prior authorization and step therapy exception request forms section on the prior authorization forms page. Please provide the physician address as it is required for physician notification. You may need to install a PDF reader program to view these files. If you need a prescription drug that is not covered by your outpatient prescription drug benefit, your physician or an authorized member of his or her staff may submit for prior authorization from Blue Shield. The following prescription drug forms are available as PDF files. Select the Drug List Search tab to access up-to-date coverage information in your drug list, including – details about brands and generics, dosage/strength options, and information about prior authorization of your drug. This . Your doctor can submit online or call 1-855-457-0407. Have your doctor fax in completed forms at 1-877-243-6930. The most commonly requested prior authorization fax forms for procedures, injectable drugs (office administered and home self-administered) and oral/topical drugs, including templates to be used for authorization notices to Blue Shield TotalDual (HMO D-SNP) and Inspire (HMO D-SNP) members. Attach any additional documentation that is important for the review, e. g. The pharmacy is authorized to dispense up to a 72-hour supply while awaiting the outcome of this request. Complete ALL information on the form. Once you have completed and submitted the request, Blue Cross & Blue Shield of Mississippi will communicate with you by email if we need more information. Please fill out the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form and fax it to (844) 474-3347. Use the appropriate Medication Authorization Request Form below to request prior authorization for a medication that's covered under a member's medical benefits and administered in an outpatient location. If you have questions regarding a Medicaid PA request, call us at 844-396-2330. For drug formulary information and to request prior authorization for Commercial and Medicare member outpatient prescription drugs and home self-administered injectables, call (800) 535-9481. fkhak nlgouuj oxgk lpth xdbclcx sgbo ktmcb snbf ghyjkoy tra