CurrentBlue Cross Blue Shield - AlabamaPolicy N/A

Prescription Drug Prior Authorization Request Form and Submission Instructions

This document is a template and instructions for submitting prior authorization, step therapy exception, quantity limit exception, appeals, and non-formulary or generic exception requests for prescription drug benefits for Blue Cross Blue Shield - Alabama members; it applies to prescribers and their staff completing pharmacy benefit authorization requests.

Policy Summary

PayerBlue Cross Blue Shield - Alabama

PolicyPrescription Drug Prior Authorization Request Form and Submission Instructions

Policy CodePolicy N/A

Change TypeTemplate/administrative — no material coverage changes

Effective Date

Next Review Date

Key ActionComplete and sign the prior authorization/exception form with required patient and prescriber details, attach supporting documentation, and submit via fax to 1-866-606-6021 or mail to Pharmacy Review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6request types listed

7required data sections

1fax provided

1mailing address provided

Information Required for Authorization Review

Policy Summary

PayerBlue Cross Blue Shield - Alabama

PolicyPrescription Drug Prior Authorization Request Form and Submission Instructions

Policy CodePolicy N/A

Change TypeTemplate/administrative — no material coverage changes

Effective Date

Next Review Date

SourceLink

On This Page

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Required information for authorization review

Information the payer requires to evaluate authorization requests:

Patient demographics: patient name, address, date of birth, contract number (include prefix).

Prescriber information: prescriber name, practice type, specialty, practice address, NPI, phone/fax.

Request type: indicate one of Prior Authorization, Step Therapy Exception, Quantity Limit Exception, Appeal, Mandatory Generic Exception, or Non‑Formulary Exception.

Authorization action: specify Initial Authorization or Authorization Renewal (attach additional medical information as needed).

Treatment information: drug name, strength, frequency, quantity requested; duration of disease; place of service; route of administration; whether a healthcare professional will administer; ICD‑10 diagnosis code(s); medical rationale with chart notes if available; list of prior medication trials including drug, strength/frequency, dates of therapy, and outcome for each trial.

Signature: prescriber signature and date certifying the information is complete and correct (required for processing); note that medications received via manufacturer coupons or samples are not acceptable as prior therapy justification.

Submission: send the signed and completed form via fax to 1-866-606-6021 or mail to Pharmacy Review, PO Box 529, Auburn, AL 36831.

Submission Steps and Documentation Requirements

Prior Authorization

Prior Authorization / Exception Submission Steps

Complete and submit a signed prior authorization or exception request using the full form. Include patient demographics (name, home address, city, state, zip, date of birth, contract number with prefix), request type (prior authorization, step therapy exception, quantity limit exception, appeal, mandatory generic exception, non‑formulary exception), and whether this is an initial authorization or renewal. Attach any additional medical information as needed.

Patient-identifying information: Patient name, home address, city, state, zip, date of birth, contract number (include prefix).
Request type: check appropriate box (Prior Authorization; Step Therapy Exception; Quantity Limit Exception; Appeal; Mandatory Generic Exception; Non‑Formulary Exception).
Request timing: check Initial Authorization or Authorization Renewal; attach additional medical information when applicable.

Documentation Required

Required Treatment and Medical History

Provide complete treatment and clinical documentation: list drug name, strength, frequency, quantity requested, duration of disease (years), place and route of administration, and whether a healthcare professional will administer. Include ICD‑10 codes, medical rationale (attach chart notes if possible), and a full treatment history showing medications tried, strengths/frequencies, dates of therapy, and outcomes. Indicate co‑morbid conditions that may affect therapy.

Treatment details: Drug/Strength/Frequency/Quantity requested; Duration of disease; Place of service; Route of administration; Healthcare professional to administer (Yes/No).
Clinical coding and rationale: ICD‑10 codes and medical rationale; attach chart notes when available.
Treatment history: For each prior medication include drug, strength/frequency, dates of therapy, and outcome of therapy (list up to 5).
Comorbidities: State whether any co‑morbid conditions affect therapy and list them if present.

Documentation Required

Signature and Acceptable Documentation

The prescriber’s signature and date are required for processing. Attach any additional medical justification. Do not rely on manufacturer coupons or free samples as proof of prior therapy—these are not acceptable. This form is for prescription drug benefit authorization only and must be completely filled out.

Prescriber Signature: Required for processing; include date.
Acceptable attachments: chart notes, documentation of prior therapies (not manufacturer coupons or samples).
Form completeness: the form must be completely filled out to be processed.

Note

Submission Instructions

Submit the signed and completed form by fax or mail to Pharmacy Review.

Fax: 1‑866‑606‑6021 (Fax the signed and completed form to Pharmacy Review).
Mail: Pharmacy Review, Post Office Box 529, Auburn, AL 36831.

Request Type Definitions

inv-05: Prior Authorization

TermPrior Authorization

DefinitionA request type option on the form used to request coverage approval before dispensing a medication.

Form locationListed under Request Type on the General Information section of the prior authorization form.

When to useSelect when requesting initial coverage approval prior to dispensing a medication.

Related request optionsAppeal, Step Therapy Exception, Quantity Limit Exception, Mandatory Generic Exception, Non-Formulary Exception (other request types listed on the form).

inv-06: Authorization Renewal

TermAuthorization Renewal

DefinitionAn option to request continuation of an already-authorized medication.

Form locationListed as 'Authorization Renewal' under Request Type on the Request Type section of the form.

Required supporting infoInclude drug details, ICD-10 diagnosis, prior medication trials and outcomes, duration, and any additional medical information as requested on the form.

Signature requirementPrescriber signature is required for processing the renewal request.

OpenPayer

Prescription Drug Prior Authorization Request Form and Submission Instructions

Information Required for Authorization Review

Diagnosis Coding

Submission Steps and Documentation Requirements

Request Type Definitions