CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

OptumRx Prior Authorization Request Form

Provider-facing prior authorization request form used by OptumRx (Blue Cross Blue Shield - South Carolina) to request coverage for listed nasal steroid/antihistamine products (Beconase AQ, Dymista, Flonase, Nasacort, Omnaris, Qnasl, Rhinocort, Zetonna). The form collects provider, medication, clinical diagnosis, trials of formulary alternatives, contraindications, adverse reactions, dosing guideline adherence, and other clinical justification required for PA determination.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyOptumRx Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete and sign the prior authorization form with required provider, member, medication, ICD-10 diagnosis, dosing, and clinical justification details; submit via CoverMyMeds (go.covermymeds.com/OptumRx) or fax to 844-403-1029.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or policy content.

8Listed Medications on Form

Coverage Summary

Scope: Provider-facing prior authorization request form used by OptumRx (Blue Cross Blue Shield - South Carolina) to request coverage for listed nasal steroid/antihistamine products. The form specifically lists 8 medications and names the example products: Beconase AQ, Dymista, Flonase, Nasacort, Omnaris, Qnasl, Rhinocort, Zetonna. The form collects provider, medication, clinical diagnosis (ICD-10), trials of formulary alternatives, contraindications, adverse reactions, dosing guideline adherence, and other clinical justification required for PA determination.

Prior Authorization Required Clinical Criteria

Coverage consideration when ALL of the following are provided and documented:

ALL of the following

Provider submits completed prior authorization form (provider and medication information, prescriber's signature).
Form may be faxed to 844-403-1029 or submitted via CoverMyMeds link.
Patient diagnosis for the requested medication is provided.
ICD-10 code(s) must be supplied on the form.
Prescribed dosing is within manufacturer's published dosing guidelines or dosing guidelines found in accepted compendia/current literature.
Yes/No checkbox on form required.
One of the following must be documented
- Trial and failure or intolerance to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of the preferred formulary/preferred drug list alternatives for the given diagnosis.
  Examples listed: budesonide nasal spray, flunisolide spray, fluticasone spray, triamcinolone spray, mometasone spray. Document medications tried, dates, and reason for failure(s).
- Documented contraindication to the listed formulary alternatives.
  If yes, medication names and contraindication must be documented.
- Documented adverse reaction to OR reasonably expected adverse reaction to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of the listed formulary agents for the requested indication.
  If yes, document medication name(s) and adverse reaction(s).
- Clinical condition for which there is no listed formulary agent to treat the condition based on published guidelines or clinical literature.
  If yes, document the clinical condition.

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Provider Actions & Requirements

Prior Authorization

Submit completed PA form

Providers must complete and sign the prior authorization form with required provider, member, medication, diagnosis (ICD-10), dosing, and clinical justification details; submit via CoverMyMeds (go.covermymeds.com/OptumRx) or fax to 844-403-1029.

Submit electronically via CoverMyMeds: go.covermymeds.com/OptumRx
Fax completed form to 844-403-1029

Documentation Required

Document trials, contraindications, or adverse reactions

For requests citing trial/failure, contraindication, or adverse reaction, document medication names, dates of trials, reasons for failure, contraindication details, or adverse reaction details on the form.

Medication names tried (e.g., budesonide nasal spray, flunisolide spray, fluticasone spray, triamcinolone spray, mometasone spray)
Dates of each trial
Reason for treatment failure or intolerance for each trial
Details of documented contraindications (medication name and nature of contraindication)
Details of documented or expected adverse reactions (medication name and description of reaction)

Denial Risk

Incomplete requests may be denied

Request may be denied unless all required information (including signature and clinical documentation) is received.

Prescriber's signature and date
Patient diagnosis with ICD-10 code(s)
Prescribed dosing and statement that dosing is within manufacturer or compendia guidelines
Clinical justification (trial/failure documentation, contraindications, or adverse reaction details)

Background

Background: OptumRx has partnered with CoverMyMeds to receive prior authorization requests, which can save time and often deliver real-time determinations. Providers are directed to go.covermymeds.com/OptumRx to submit requests electronically.

Purpose of the form: The form is used for prior authorization requests for several branded and generic intranasal corticosteroid/antihistamine products (for example, the form title lists Beconase AQ, Dymista, Flonase, Nasacort, Omnaris, Qnasl, Rhinocort, Zetonna). It requires clinical documentation such as patient diagnosis (ICD-10), confirmation that dosing is within manufacturer's or accepted compendia guidelines, documentation of trials and failures or intolerances to formulary alternatives, documented contraindications, or documented/adverse reaction information to support the PA determination.

Defined workflow: Providers may submit completed prior authorization forms electronically via CoverMyMeds (go.covermymeds.com/OptumRx) or fax the form to 844-403-1029. The form includes required provider and medication information and the prescriber's signature; requests may be denied if all required information is not received.

Majority (in class): Defined on the form as two or more in a class with at least two alternatives or one in a class with only one alternative.