CurrentBlue Cross Blue Shield - AlabamaPolicy N/A

Prescription Drug Prior Authorization Request Form

Form and instructions for prescribers to request prior authorization, renewals, quantity or non‑formulary exceptions, step therapy exceptions, or appeals for pharmacy benefits for Blue Cross Blue Shield - Alabama members.

Policy Summary

PayerBlue Cross Blue Shield - Alabama

PolicyPrescription Drug Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the signed prior authorization/exception/appeal form with clinical rationale, ICD-10 codes, medication history, and supporting chart notes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax & mailsubmission methods

1-866-606-6021fax contact

multiplerequest types

requiredsignature

Coverage Criteria & Required Information

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Form submission requirements

Information required to support coverage determination:

ALL of the following

Patient identification (complete patient name and demographics)
Prescriber information (name, contact, NPI)
Drug, strength, frequency, and quantity requested
Duration of disease/therapy (years)
Place of service and route of administration
Healthcare professional to administer (yes/no)
ICD-10 codes (enter diagnosis codes to support the request)
ICD-10 codes should be provided on the form
Medical rationale for use (include chart notes if possible)
Attach any additional medical justification as available
List of medications the patient has tried for this condition (up to 5): include drug, strength/frequency, dates of therapy, and outcome of therapy
Manufacturer coupons or samples are not acceptable as prior therapy
Comorbid conditions that will affect therapy (if applicable), with explanation
Prescriber signature (required for processing)

Diagnosis, Medication History, and Coding Details

Diagnosis codingICD-10

ICD-10

Diagnosis codes required to support the request (enter ICD-10 codes on form)

Medication trials documented

Required prior medication detailsList up to 5 prior medications tried (include drug name, strength/frequency, dates of therapy, and outcome of therapy).

Include current and titration historyIndicate current medications and any dose titration history when applicable.

Maximum entriesForm provides space for up to 5 prior medication entries (1–5).

Unacceptable prior therapy evidenceManufacturer coupons or samples are not acceptable as prior therapy.

Document co-morbid impactIf co-morbid conditions affect therapy, list them on the form to support the medication history context.

Provider Steps to Request Authorization or Exception

Prior Authorization

Complete and sign prior authorization/exception form with clinical rationale and medication history

Complete and submit the signed prior authorization/exception/appeal form with clinical rationale, ICD-10 codes, medication history (include dates and outcomes for up to five prior medications), and any supporting chart notes; indicate request type (Initial Authorization or Authorization Renewal) and duration/administration details as applicable. Note that medications received through manufacturer coupons or samples are not accepted as justification of prior therapy. Prescriber signature is required for processing.

Include ICD-10 diagnosis codes on the form.
List prior medications tried (up to 5) with dates and outcomes; manufacturer coupons/samples are not acceptable.
Attach chart notes or additional medical justification as needed.
Indicate request type (Initial Authorization or Authorization Renewal) and specify duration/administration details.

Documentation Required

Submission instructions — fax or mail the signed form

Send the completed and signed form to Pharmacy Review by fax or mail. Fax the form to 1-866-606-6021 or mail to Pharmacy Review, Post Office Box 529, Auburn, AL 36831.

Fax: 1-866-606-6021
Mail: Pharmacy Review, PO Box 529, Auburn, AL 36831

Request Type and Authorization Definitions

Request Type (select one)

Prior AuthorizationRequest Type option on form for standard prior authorization requests.

Step Therapy ExceptionRequest Type option to request an exception to step therapy requirements.

Quantity Limit ExceptionRequest Type option to request an exception to quantity limits.

AppealRequest Type option to appeal a prior coverage decision.

Mandatory Generic / Non‑Formulary ExceptionRequest Type options include Mandatory Generic Exception and Request for Non‑Formulary Exception.

Authorization

Initial AuthorizationAuthorization option to request a new (initial) authorization for therapy.

Authorization RenewalAuthorization option to request renewal of a previously authorized therapy.

Attach supporting informationPlease attach any additional medical information as needed to support the initial request or renewal (chart notes, rationale, ICD‑10 codes).