Currentblue cross blue shield - alabamaPolicy N/A

NON-COVERED PROVIDER ADMINISTERED DRUG EXCEPTION AUTHORIZATION REQUEST FORM

Form and instructions for requesting authorization of provider-administered drug benefits for drugs that are not covered by the plan. Specifies required patient, prescriber, treatment, and documentation fields and submission methods.

Policy Summary

Payerblue cross blue shield - alabama

PolicyNON-COVERED PROVIDER ADMINISTERED DRUG EXCEPTION AUTHORIZATION REQUEST FORM

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionProviders must fully complete this form, include required documentation (medical rationale, prior therapy history, ICD-10 codes), obtain prescriber signature, and submit via email or mail to Pharmacy Review for authorization consideration.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — administrative form only.

1Form type

0Policy-specific clinical criteria included

Policy overview

This administrative form requests authorization for provider-administered drugs that are not covered by the plan. It collects patient information (name, address, DOB, contract number), prescriber information (name, practice type, specialty, practice address, NPI, phone, fax), treatment details (drug, strength/frequency/quantity requested, duration of disease, place of service, route of administration, whether a healthcare professional will administer), ICD-10 codes, medical rationale and chart notes, and a history of prior medications tried (up to five entries with dates and outcomes).

The form requires the prescriber’s signature for processing and instructs providers to attach any additional medical justification. Requests must indicate Initial Authorization or Authorization Renewal. Completed and signed forms may be submitted via email to Pharm-Pol-Rvw-Comm@bcbsal.org or mailed to Pharmacy Review at 450 Riverchase Parkway East, Birmingham, AL 35244.

Form completion / submission requirements

Form Completion / Submission Requirements

Request will be processed when all required sections are completed and signed:

Request type: Indicate request type: Initial Authorization or Authorization Renewal (one must be checked).
Patient information: Provide patient information: name, home address, city, state, zip, date of birth, contract number (include prefix).
Prescriber information: Provide prescriber information: name, practice type (PCP checkbox available), specialty, practice address, city, state, zip, NPI, office phone, office fax.
Treatment information: Provide treatment information: drug, strength, frequency, quantity requested; duration of disease (years); place of service; route of administration; healthcare professional to administer (Yes/No).
ICD-10 codes: Include ICD-10 codes for the indication.
Medical rationale and chart notes: Provide medical rationale for use and attach chart notes if possible.
Prior medications: List prior medications tried for this condition (drug, strength/frequency, dates of therapy, outcome) up to five entries.
Co-morbid conditions: Indicate co-morbid conditions affecting therapy and list if present.
Prescriber signature and date are required for processing the request.
Additional justification: Attach any additional medical justification as needed.

Provider responsibilities and submission instructions

Prior Authorization

Complete and submit exception request for non-covered provider-administered drugs

Providers must fully complete the Non-Covered Provider Administered Drug Exception Authorization Request Form, provide required documentation including medical rationale, prior therapy history, and ICD-10 codes, obtain the prescriber signature, and submit the signed form to Pharmacy Review for authorization consideration via the listed email or mail address.

Email: Pharm-Pol-Rvw-Comm@bcbsal.org
Mail: Pharmacy Review, 450 Riverchase Parkway East, Birmingham, AL 35244

Documentation Required

Attach chart notes and prior therapy documentation

Attach chart notes and documentation of prior medications tried for this condition, including dates of therapy and outcomes. Note that medications received through manufacturer coupons or samples are not accepted as justification of prior therapy.

Billing Rule

Include contract number

Include the member's contract number (with prefix) on the form (patient information section) so the authorization can be processed.

Who and what this form applies to

Scope & Submission

Applies toForm and instructions for requesting authorization of provider-administered drug benefits for drugs that are not covered by the plan.

PurposeRequest authorization/exception for non-covered provider-administered drugs

Required attachmentsmedical rationale (chart notes), prior therapy history, ICD-10 codes, prescriber signature

Submission methodsEmail to Pharm-Pol-Rvw-Comm@bcbsal.org or mail to Pharmacy Review, 450 Riverchase Parkway East, Birmingham, AL 35244

Required fieldsPatient, prescriber, treatment information, ICD-10 codes, prior medications tried, co-morbid conditions (if any)

Request typesInitial Authorization or Authorization Renewal (one must be checked)