Preventive Services Zero Copay Exception
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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.
No material clinical or coverage changes in this revision.
Coverage Authorization Criteria
Authorization submission criteria
Coverage authorization will be considered when ALL of the following are provided:
Provider must attest medication is medically necessary as a preventive service.
Contact CVS/Caremark at 1-800-294-5979 for questions regarding the prior authorization process.
No explicit coverage exclusions are listed on this form.
If the provider indicates the requested drug is not medically necessary as a preventive service (the form includes a Yes/No question), that response and accompanying attestation will not support a zero-copay exception for the medication.
Diagnosis / Coding
| Diagnosis (ICD) Code(s) | Place to record relevant ICD diagnosis codes on form |
Provider Submission and Documentation Actions
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.
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.
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
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
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