CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Olux-EC / Olux-E Prior Authorization Request Form (topical corticosteroid)

This document is a prior authorization (PA) request form used by OptumRx for Olux-EC / Olux-E topical corticosteroid products to collect provider, medication, and clinical information to support a PA determination for treatment of corticosteroid-responsive dermatoses.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyOlux-EC / Olux-E Prior Authorization Request Form (topical corticosteroid)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must submit the completed Olux-EC / Olux-E prior authorization form with required clinical documentation (trials, contraindications, adverse reactions, dosing justification) faxed to 844-403-1029 or via CoverMyMeds/OptumRx portal.

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Primary Indication captured

2Required alternative trials

8444031029Fax for submission

Policy summary & scope

This is a prior authorization (PA) request form used by OptumRx for Olux-EC / Olux-E topical corticosteroid products to collect provider, medication, and clinical information to support a PA determination for treatment of corticosteroid-responsive dermatoses. The form captures required provider identifiers (Member name, Insurance ID#, NPI, office phone/fax, address), medication details (name, strength, directions for use), and the clinical rationale for therapy.

The form collects specific clinical items to determine coverage, including the selected diagnosis (treatment of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses or other diagnosis with ICD-10 code), documentation of prior trials and reasons for failure or intolerance to formulary alternatives, contraindications or adverse reactions to formulary agents, whether there is no listed formulary agent per guidelines, and confirmation that prescribed dosing is within manufacturer's or accepted compendia dosing guidelines. The request may be denied unless all required information is received.