CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Clinical Quantity Limit Override Request Form

A pharmacy program form used by prescribers to request an override of clinical quantity limits for medications for Blue Cross and Blue Shield of Oklahoma members. It collects patient, prescriber, drug, diagnosis, and supporting documentation details and provides submission instructions.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyClinical Quantity Limit Override Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionPrescriber must complete and fax the Clinical Quantity Limit Override Request Form with all requested information to Pharmacy Programs at 918-551-3546 to request a quantity limit override.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is an administrative form for requesting pharmacy quantity limit overrides.

1Form pages referenced

faxSubmission channel (fax)

Clinical Quantity Limit Override Request Form — Overview

This is a pharmacy program form used by prescribers to request an override of clinical quantity limits for medications for Blue Cross and Blue Shield of Oklahoma members. It instructs prescribers to print and provide all requested information and to fax the completed form to Pharmacy Programs at 918-551-3546.

The form captures prescriber contact details (contact person, phone, prescribing physician name, fax, physician NPI, DEA, and address), patient identifiers (patient name, date of birth, Subscriber ID which must be the patient's BCBSOK ID and not the physician's, and group), and medication details (drug name, strength, quantity requested per month and therapy duration, route of administration, and medication directions).

It also collects diagnostic and treatment information including an ICD-9 diagnosis code, previous drug therapies tried and their outcomes, and requires supporting documentation (a detailed letter of medical necessity and copies of patient medical records). The prescriber must sign and date the form certifying the information is true and correct, and after 72 hours status inquiries may be made via the customer service number on the member ID card; responses will be sent by mail.

Document metadata

Policy PayerBlue Cross Blue Shield - Oklahoma

SubjectClinical Quantity Limit Override Request Form

Document Typeadministrative

StatusCURRENT

Pages referenced1

Submission channelfax

Scope summaryA pharmacy program form used by prescribers to request an override of clinical quantity limits for medications for Blue Cross and Blue Shield of Oklahoma members. It collects patient, prescriber, drug, diagnosis, and supporting documentation details and provides submission instructions.

Actions Required by Prescribers

Prior Authorization

Submit Quantity Limit Override Request

Prescriber must complete and fax the Clinical Quantity Limit Override Request Form with all requested information to Pharmacy Programs at 918-551-3546 to request a quantity limit override.

Documentation Required

Required supporting documentation

Include a detailed letter of medical necessity and copies of patient medical records documenting all therapies utilized for the diagnosis and previous drug therapies tried and outcome.

Documentation Required

Required prescriber attestation

Prescribing physician must sign and date the form certifying the information is true and correct under penalty of law.

Billing Rule

Use patient BCBSOK ID

Provide the patient's BlueCross BlueShield of Oklahoma ID number (not the physician's) when completing the Subscriber ID field; requests cannot be processed for members not covered by BCBSOK (including Federal employees and Medicare Part D members).

Prior Authorization

Status inquiry timing

After 72 hours, callers may contact customer service (number on back of member ID card) for a status update; responses will be sent by mail, not fax.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyClinical Quantity Limit Override Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionPrescriber must complete and fax the Clinical Quantity Limit Override Request Form with all requested information to Pharmacy Programs at 918-551-3546 to request a quantity limit override.

On This Page

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Clinical Quantity Limit Override Request Form

Clinical Quantity Limit Override Request Form — Overview

Requested Code Fields

Actions Required by Prescribers

Key Definitions

Revision History