CurrentBlue Cross Blue Shield - IowaPolicy P-2322149

Preventive Services Zero Copay Exception

Form and process to request authorization of a zero-copay exception for preventive medications/services for Blue Cross Blue Shield - Iowa members; used by prescribers to submit clinical and administrative information to request coverage when preventive service copay is to be waived.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyPreventive Services Zero Copay Exception

Policy CodePolicy P-2322149

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax signed, completed prior authorization form to CVS/Caremark at (888) 836-0730 and contact 1-800-294-5979 with questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1authorization request form included

faxsubmission channel

1-800-294-5979PA contact

800-524-9242language assistance

Coverage Authorization Criteria

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Authorization submission criteria

Coverage authorization will be considered when ALL of the following are provided:

Required form elements: Completed patient information, prescriber information, diagnosis with ICD code(s), medication details (name, strength, frequency, quantity, expected length of therapy), and provider signature with date.

Provider must attest medication is medically necessary as a preventive service.

Submission method: Signed form faxed to CVS/Caremark at 1-888-836-0730.

Contact CVS/Caremark at 1-800-294-5979 for questions regarding the prior authorization process.

Provider Submission and Documentation Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage. Submit the completed prior authorization request via fax to CVS/Caremark at 1-888-836-0730. For questions about the prior authorization process, contact CVS/Caremark at 1-800-294-5979.

Note

Provider Action — Submit Signed Form

Provider must complete and sign the form and fax it to CVS/Caremark at 1-888-836-0730. Ensure the fax is sent from a secure location in accordance with HIPAA requirements.

Documentation Required

Complete Required Provider Form Fields

The provider must complete all required sections of the form: patient information, prescriber information, diagnosis (including ICD code and disease duration), medication details (name, strength, frequency, quantity), and expected length of therapy. Include the prescriber signature and date.

Patient: name, ID, group number, DOB, phone
Prescriber: name, specialty, address, phone, fax, contact person
Diagnosis: diagnosis name, disease duration, ICD code(s)
Medication: name, strength, frequency, quantity, expected length of therapy
Signature: provider (or authorized) signature and date

Denial Risk

Incomplete Form Risk

Form cannot be evaluated without required clinical information. Incomplete or unsigned forms may result in inability to authorize coverage.

Background

This document is an administrative request form used to determine whether a requested drug qualifies for a preventive services zero-copay exception. It requires the prescriber to attest that the medication is medically necessary as a preventive service, sign and date the form, and make supporting documentation available for review by the claims processor, plan sponsor, or applicable regulatory agencies.

Definitions and Attestations

Medical necessity attestation

Attestation statementProvider must attest that the medication requested is medically necessary for the patient as a preventive service and confirm supporting documentation is available for review.

Yes/No declarationForm includes a Yes/No question: 'Is the requested drug medically necessary for the patient as a preventive service?' (checkboxes for Yes or No).

Provider signature requirementProvider (or authorized) signature and date are required on the form to complete the attestation.

Supporting documentation availabilityProvider attests that documentation supporting the information is available for review by the claims processor, health plan sponsor, or applicable regulatory agency.

Consequence of incomplete informationForm cannot be evaluated without required clinical information; incomplete forms may result in inability to authorize coverage.