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    v1.0.28
    OpenPayerPolicy UpdatesPreventive Services & ScreeningBlue Cross Blue Shield AL preventive coverage | Op…
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    Currentblue cross blue shield - alabamaPolicy N/A

    HSA Preventive List Attestation Form Coverage Criteria

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    This document is the prescriber-completed attestation and information form required for medications to be considered preventive care under the HSA Preventive List benefit for Blue Cross Blue Shield - Alabama members.

    Policy Summary
    Payerblue cross blue shield - alabama
    PolicyHSA Preventive List Attestation Form Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionPrescriber must complete, sign, and fax or mail the attestation form to the Pharmacy Department for preventive medication coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1required prescriber form
    diagnosis attestationclinical attestation element

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    signature required
    signature field present
    faxsubmission method

    Coverage Criteria

    Preventive medication coverage criteria

    Covered as preventive when ALL of the following are met

    Diagnosis or attestation: Member has an appropriate diagnosis documented via medical claims or prescriber attestation on this form

    Form requires ICD-9 or ICD-10 diagnosis entry and physician signature

    Completed prescriber form: Form completed by the prescriber including patient, insurance, prescriber/clinic, medication details, dosing, quantity, and dated physician signature

    Only the prescriber may complete the form; attach additional medical information as needed

    Submission: Signed form faxed or mailed to the Pharmacy Department at the provided contact for processing

    Submission address and toll-free fax provided on form

    The form must be completed only by the prescriber. No other exclusions are specified on the form; all required fields and the attestation must be provided by the prescribing clinician.

    Medications will not be considered preventive under this benefit unless the member has an appropriate diagnosis documented via medical claims or a prescriber attestation of an appropriate medical diagnosis on the form.

    Diagnosis and Coding

    Diagnosis codes (form fields)mixed
    ICD-9 fieldPatient Diagnosis with ICD-9 Code (form field)
    ICD-10 fieldICD-10 Code (form field)

    Provider Actions & Submission Requirements

    Prior Authorization

    Submission and prescriber requirement

    The completed and signed attestation form must be faxed or mailed to the Pharmacy Department at the contact provided on the form; only the prescriber may complete and sign the form for processing.

    • Mailing address: Attn: Pharmacy Department, 450 Riverchase Parkway East, Birmingham, Alabama 35244-2858.
    • Toll-free fax: 205-220-9562
    Step Therapy

    Step therapy — none specified

    There are no step therapy requirements specified on the attestation form; no prior medication trials are listed as conditions on the form.

    Background

    Medications classified as preventive care under this benefit are those taken to prevent the onset of disease in members with risk factors that are not yet clinically apparent, or to prevent recurrence of a previously recovered disease. Members must have either medical claims documenting an appropriate diagnosis or a prescriber attestation on the form to qualify medication use as preventive.

    Definitions

    Preventive medications — definition and qualification
    DefinitionMedications considered preventive care when taken by a person with risk factors for a disease not yet clinically apparent or to prevent recurrence of a recovered disease.
    Qualification requirementMembers must have an appropriate diagnosis documented via medical claims or a prescriber attestation of an appropriate medical diagnosis.
    Benefit contextApplies to members with the HSA Preventive List benefit.
    Attestation sourcePrescriber-completed attestation on the required form satisfies the attestation requirement.
    Clinical intentUsed to prevent onset of disease in at-risk persons or to prevent recurrence after recovery.
    Policy Summary
    Payerblue cross blue shield - alabama
    PolicyHSA Preventive List Attestation Form Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionPrescriber must complete, sign, and fax or mail the attestation form to the Pharmacy Department for preventive medication coverage.
    SourceLink
    On This Page
    Coverage CriteriaDiagnosis and CodingProvider Actions & Submission RequirementsBackgroundDefinitions
    Documentation Required

    Required form fields and attachments

    Prescriber must complete patient identification, insurance, prescriber/clinic information, and medication details on the form and attach additional medical information as needed.

    • Patient fields: date, first/last name, DOB, address, phone.
    • Insurance fields: Member ID Number, Group Number.
    • Prescriber/clinic fields: Prescriber name, NPI, specialty, clinic name, contact, phone, secure fax.
    • Medication fields: Patient diagnosis with ICD-9 code, ICD-10 code, medication and strength, dosing schedule, quantity per month.
    • Physician's dated signature is required.
    Denial Risk

    Diagnosis attestation requirement

    Members must have an appropriate diagnosis documented via medical claims or prescriber attestation; failure to provide an appropriate diagnosis or attestation may prevent medications from being considered preventive care under this benefit.