Prior authorization form — Brand contraceptive copay waiver
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This document is a prior authorization request form used by providers to request a copay waiver for a brand contraceptive when a preferred contraceptive is inappropriate; it applies to Blue Cross Blue Shield - Maine members and providers submitting the request.
No material clinical or coverage changes in this revision.
Coverage Criteria
Approval criteria via attestation
Covered when ALL of the following are met
Form must be completed and signed by physician (signature and date required)
Provider Actions and Requirements
Prior Authorization Required
Prior authorization required — A completed prior authorization form must be submitted (including answers to two attestation questions and physician signature) to request a copay waiver.
- Form: Prior Authorization Request Brand Contraceptive Copay Waiver
- Required: Answers to both attestation questions
- Required: Signature and date from ordering physician
Preferred-contraindication Attestation
Provider must confirm that preferred contraceptives are inappropriate for the patient by answering the preferred-contraindication attestation question on the form.
- Question 1 on the form: "Is the requested contraceptive medically necessary because the preferred contraceptives are inappropriate for this patient?" — Provider must select Yes and document rationale in the medical record.
Required Attestations and Signature
Provider must answer attestation questions on the form confirming medical necessity and that documentation in the medical record supports the request, and must sign and date the form.
- Question 2 on the form: "Is the medical necessity attested to above for the specific non-preferred contraceptive drug supported by medical record documentation?" — Provider must select Yes and ensure supporting records are available.
- Signature block: "Signature of Physician" and date are required on the submitted form.
Attestation and Documentation Needed
Failure to attest that the requested brand contraceptive is medically necessary because preferred contraceptives are inappropriate, or failure to provide supporting documentation and physician signature, may result in denial of the copay waiver.
- Incomplete attestation answers, missing documentation in the medical record, or absent physician signature/date may lead to denial.
Background
This form is administrative and is used to request a Brand Contraceptive Copay Waiver for Blue Cross Blue Shield - Maine members when a preferred contraceptive is inappropriate. The completed prior authorization form documents the provider’s clinical justification through two attestations: (1) that the requested contraceptive is medically necessary because preferred contraceptives are inappropriate for this patient; and (2) that the medical necessity for the specific non-preferred contraceptive drug is supported by medical record documentation. The form must be signed and dated by the physician.
A completed prior authorization request (the Brand Contraceptive Copay Waiver form) must be submitted to request a copay waiver. Failure to attest that the requested brand contraceptive is medically necessary because preferred options are inappropriate, or failure to attest that the medical necessity is supported by the medical record, may result in denial of the request.
Definitions
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