Prior authorization request form for prescription and provider-administered medications (including opioids)
Customize your policy alerts
Sign up for all blue cross blue shield - louisiana policy alerts
Know when blue cross blue shield - louisiana releases new policies or updates existing guidance.
Monitor payer policy activity
This document is a prior authorization submission form used by prescribers to request coverage for prescription drugs and provider-administered medications (including opioid-specific attestation) for Blue Cross and Blue Shield of Louisiana members. It captures prescriber, patient, clinical, and drug administration details needed to process authorization.
No material clinical or coverage changes in this revision.
Coverage and Authorization Criteria
Authorization criteria
Coverage evaluation requires completion of the following information and attestations
See Section IV
See Sections V and VII
See Section IV
See Sections VI and VII and opioid attestation list
The form does not list any separate, explicit clinical exclusions beyond the opioid-specific attestations. However, for opioid long-acting therapy the prescriber must attest to items A–L in the opioid attestation section. Notably, attestations J and K exclude opioids intended for acute pain or for as‑needed (PRN) use from consideration as long‑acting opioid therapy.
Requests for long‑acting opioid medications must not be for treatment of acute pain, mild pain, or for as‑needed (PRN) analgesia. The prescriber must attest that the medication has not been prescribed to treat acute pain, mild pain, or pain not expected to persist (attestation J) and that it has not been prescribed for as‑needed use (attestation K). These attestations establish that acute/PRN indications are not appropriate for long‑acting opioid therapy.
Billing and Diagnosis Codes
| HCPCS/CPT-4 | Field for provider-administered drug procedure/billing code |
| NDC | Field for product NDC number |
| ICD-10 | Primary and secondary diagnosis code fields |
Provider Submission Requirements and Documentation
Prior Authorization Submission Requirements
Prior authorization is required for many drug requests. Submit the requested drug name, strength, dosage form, route, total quantity, days' supply, dosage interval/directions for use, and expected therapy duration or start date. Indicate whether this is a new therapy (initial request) or a continuation/reauthorization.
- Requested drug name, strength, dosage form, route
- Quantity, Days' supply, Dosage interval/Directions for use
- Expected therapy duration / Start date
- Indicate New therapy vs Continuation/Reauthorization
Missing Coding for Provider‑Administered Drugs
For provider-administered drugs, include HCPCS/CPT-4 code and/or NDC. Provide the dose per administration and any other applicable codes. If the patient will not receive the drug in the prescriber's office, include the servicing provider/facility name and NPI. Omission of HCPCS/CPT-4, NDC, or dose-per-administration may result in rejection or processing delays.
- HCPCS/CPT-4 code (required when applicable)
- NDC# (if available) and Dose per administration
- Other applicable codes
- If not administered in prescriber's office, provide servicing provider/facility name and NPI
Required Clinical Documentation
Provide complete clinical documentation to support medical necessity. Incomplete or missing primary diagnosis, ICD-10 code, dates diagnosed, or pertinent laboratory values may prevent processing of the request.
- Patient demographics and identifiers (name, DOB, member ID)
- Primary diagnosis relevant to this request with ICD-10 code and date diagnosed
- Secondary diagnosis (if applicable) with ICD-10 code and date diagnosed
- Pertinent laboratory values and dates (attach results or list below)
- For postoperative pain: date of surgery
Opioid-Specific Documentation
For opioid medication requests include opioid-specific documentation: whether the requested quantity exceeds the plan's max quantity limit and justification if it does; cumulative daily morphine milligram equivalent (MME) and justification if it exceeds the plan's daily max MME. The prescriber must complete attestations A–L (pain/function assessment, substance use screening, PMP checks, treatment plan, opioid agreement, prior short-acting opioid trial, not for acute/PRN use, etc.). If any attestation (A–L) is 'No', provide an explanation.
- Does requested quantity exceed plan max quantity limit? Yes/No — if Yes, provide justification
- Cumulative daily MME — value and indicate if it exceeds plan max MME (Yes/No). If Yes, provide justification
- Prescriber attestations A–L (see checklist): pain/function assessment; substance abuse screening; PMP access; treatment plan; failure criteria; risks/benefits discussed; opioid treatment agreement; need for continuous around-the-clock therapy; prior short-acting opioid trial; not for acute/mild/short-term pain; not PRN; prescriber reviewed product labeling
- If any attestation is 'No', explain in the provided space
Pharmacologic and Non‑Pharmacologic Treatment History / Step Therapy Exception Rationale
List prior and current pharmacologic and non-pharmacologic treatments for this diagnosis, including drug name, strength, frequency, dates started/stopped (or approximate duration), response and reason for discontinuation. Include drug allergies, height/weight if applicable. Indicate whether there is clinical evidence or patient history to support bypassing step-therapy (pre-requisite) medications and provide an explanation if yes.
- Pharmacologic & non-pharmacologic treatments: drug name, strength, frequency, dates/duration, response/reason
- Drug allergies
- Height and weight (if applicable)
- Does patient history support exception to step-therapy? Yes/No — if Yes, explain
Incomplete Clinical Information
Incomplete clinical information — missing primary diagnosis, ICD-10 code, dates, or pertinent lab results may prevent or delay processing of the request. Ensure all required fields are completed and attach relevant documents or test results.
- Ensure primary diagnosis, ICD-10 code, and date diagnosed are provided
- Provide pertinent laboratory values with test names and dates
- Attach supporting documentation when applicable (operative reports, notes, prior therapy records)
Policy Background
This form is used to collect the clinical and administrative information required to evaluate medical necessity for drug therapies, including controlled substances. For opioid requests the form captures a series of required attestations (A–L) addressing assessment, screening, PMP access, treatment plan, opioid trial history, agreement on file, and indication for around‑the‑clock therapy, and it requires the prescriber’s signature confirming the information provided.
Definitions and Key Terms
Initial Therapy Requirements
Initial therapy
Initial requests must document prior treatments and rationale if step therapy will be bypassed
See Section IV and VII
See Section VII
See Section VI (attestation I) and Section VII
Continuation / Reauthorization Criteria
Continuation therapy
Continuation/reauthorization requests require current therapy designation and prior dosing history
See Section IV and VII
See Section VII
See Sections VI and VII
Step Therapy Exceptions
| Requirement | Provider action / form field | Notes |
|---|---|---|
| Step therapy bypass explanation required | Form asks: 'Is there clinical evidence or patient history that suggests the use of the plan's pre-requisite medication(s), e.g. step medications, will be ineffective or cause an adverse reaction to the patient? ____Yes ____No' — If Yes, prescriber must 'please explain in Section VIII below.' | Prescriber must provide clinical rationale in Section VIII; absence of explanation may result in inability to process request or denial if step therapy is required. |
Administration Site and Facility Information
Identify site of care and servicing provider/NPI if offsite
Indicate on the form whether the patient will receive the drug in the physician's office; if No, provide the servicing provider or facility name and NPI.
- Check Yes/No for administration in physician's office
- If No, list servicing provider/facility name and NPI
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.