This faxback form operationalizes Blue Cross NC's prior authorization process for nonformulary exceptions and value-based prior authorization for pharmacy products. It is the required two-page prior review/certification form that prescribers must complete and sign to request coverage of a non-preferred or brand medication and to document clinical justification for exceptions.
The form collects key administrative identifiers including prescriber name, NPI (required), Blue Cross NC provider ID (all NC providers must provide their 5-digit Blue Cross NC Provider ID or Tax ID for out-of-state), contact information, and patient identifiers such as patient name, Blue Cross NC ID, date of birth, and gender.
Clinical and utilization information captured includes the diagnosis code, drug name, strength, dosage form, quantity requested and period, and a Yes/No checkbox asking whether the patient has taken the requested medication in the prior 180 days. The form also asks whether the medication is being used for seizure-related or refractory psychiatric disorders and, if so, requires medical record documentation and questions about stability on therapy and whether the patient is too critical to try other medications.
Special considerations collected on the form include whether the request is for a contraceptive medication/device (and if a non-preferred contraceptive is requested, whether medical necessity for the non-preferred version is documented), whether the medication/dose is medically necessary, and whether it treats a chronic, disabling, or life‑threatening disease.
The form requires documentation of prior medication history and rationale: whether the patient tried and failed other medications for the diagnosis, whether previously tried alternatives were detrimental or ineffective and likely to be so again, a list of previously tried/failed medications, and any medications with contraindications or intolerances. For brand drugs with an FDA A-rated generic, the provider must indicate if the generic was tried and, if a life‑threatening adverse event occurred with the generic, submit an FDA MedWatch form if completed.
Requests involving non-standard formulations (for example chewable, concentrate, elixir, film, granule, liquid, ODT, powder, sprinkle, suspension, syrup) capture additional items including patient age (e.g., 11 years or younger), inability to take solid dosage forms, concurrent use of other solid dosage medications, and enteral feeding tube use with whether the tablet/capsule can be crushed or opened for administration.
Providers must include a clinical rationale addressing alternatives not tried and supporting documentation (medical records, lab results, etc.), sign and date the form certifying accuracy, and fax the completed form with any required records to 1-800-795-9403 for Blue Cross NC members. The form warns that incomplete or inaccurate submissions may delay processing and that Blue Cross NC may request medical records and pursue remedies if documentation is inconsistent with the form.