CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Basaglar, Levemir & Tresiba Prior Authorization Request Form

Form and requirements for providers to request prior authorization of Basaglar, Levemir, or Tresiba through OptumRx (BCBS South Carolina). Affects prescribers requesting coverage for these insulin products for members.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyBasaglar, Levemir & Tresiba Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the two-page prior authorization form by fax to 844-403-1029 or via CoverMyMeds.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

844-403-1029fax

go.covermymeds.com/OptumRxportal

6 weeksmin trial

Coverage Criteria

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Initial prior authorization criteria: (1) Diagnosis selected as Type 1 diabetes mellitus, Type 2 diabetes mellitus, or Other diagnosis with ICD-10 code; (2) Documentation that patient has failed or is intolerant to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of preferred formulary alternatives for at least six weeks OR has a documented contraindication to listed formulary alternatives OR has had or would be reasonably expected to have an adverse reaction to a majority of listed formulary agents OR has a clinical condition for which no listed formulary agent is appropriate per published guidelines; (3) Prescribed dosing is within the manufacturer's published dosing guidelines or accepted compendia/current literature.see node texts

Form requires submission of supporting documentation for medication trials (including dates and reasons for failure), contraindications, adverse reactions, or clinical rationale as indicated on the form.

The Prior Authorization Request Form does not list any explicit exclusions. The form provides a selectable diagnosis list for Type 1 diabetes mellitus, Type 2 diabetes mellitus, and an Other diagnosis field where the provider must enter the specific diagnosis and an ICD-10 code (displayed on the form as "ICD-10 Code: _______________").

Coding and Diagnosis

Diagnosis codes (form entry)ICD-10

ICD-10 Code: _______________

Place to enter the diagnosis ICD-10 code on the form

Minimum formulary trial duration — at least six weeks

Minimum trial durationAt least six weeks

Applies toPreferred formulary/preferred drug list alternatives (e.g., Lantus or Toujeo)

Context on formQuestion asks if patient failed or was intolerant to alternatives for the given diagnosis for at least six weeks; documentation of medications tried, dates, and reasons required

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Complete and submit the Basaglar, Levemir & Tresiba Prior Authorization Request Form by fax to 844-403-1029 or via the payer's online prior authorization portal.

Fax: 844-403-1029
Phone for prior authorization process info: 855-811-2218 (Mon–Fri 8 a.m.–1 a.m. ET; Sat 9 a.m.–6 p.m. ET)

Documentation Required

Required Clinical Documentation

Submit documentation of all relevant clinical information with the form. Include diagnosis (with ICD-10 code), prescriber signature, and any other clinical notes or comments that may support the request.

Diagnosis and ICD-10 code
Prescriber signature and date
Any additional clinical comments or supporting notes

Step Therapy

Step Therapy / Formulary Alternatives

Provide evidence of step therapy or trials of formulary alternatives. If the patient has failed or is intolerant to a majority of preferred formulary alternatives, document medications tried, trial dates, and reasons for failure or intolerance. If a contraindication or expected adverse reaction exists to formulary alternatives, include documentation of the contraindication or adverse reaction.

Document trials of preferred formulary/preferred drug list alternatives (e.g., Lantus, Toujeo): medication names, start and end dates, and reasons for failure or intolerance
If claiming contraindication to formulary alternatives, submit documentation specifying medication name(s) and the contraindication
If claiming adverse reaction or expected adverse reaction to formulary alternatives, submit documentation specifying medication name(s) and adverse reaction(s)
If no appropriate formulary agent exists for the clinical condition, provide documentation describing the condition and supporting literature or guideline evidence

Denial Risk

Incomplete Information May Lead to Denial

This request may be denied unless all required information is received. Incomplete submissions (missing form, missing documentation of prior trials, dates, reasons for failure/intolerance, contraindications, or prescriber signature) may lead to denial.

Incomplete information may result in denial of the request
Ensure all required fields on the Basaglar, Levemir & Tresiba Prior Authorization Request Form are completed and supporting documentation is attached

Background

This two-page Prior Authorization Request Form is used to request prior authorization for the insulin products Basaglar, Levemir, and Tresiba for treatment of diabetes (Type 1, Type 2, or other specified diagnoses). It collects the patient diagnosis (including an ICD-10 code entry for "Other diagnosis"), documentation of prior trials or contraindications to preferred formulary alternatives (including trial duration and reasons for failure), and confirmation that prescribed dosing is within manufacturer or accepted compendia guidelines. The form notes that incomplete submissions can lead to denial and provides contact information for prior authorization questions.

Definitions

Majority failure/intolerance — form definition

Definition of 'majority' on formTwo or more in a class with at least two alternatives, or one in a class with only one alternative

Where usedApplied to failure, intolerance, or expected adverse reaction to preferred formulary agents (e.g., Lantus or Toujeo)

Documentation requiredIf majority failure/intolerance is indicated, submit medication(s) tried, dates of trial(s), and reason(s) for treatment failure(s) or adverse reactions

Initial Therapy Criteria

Initial therapy

Initial authorization requires documentation of prior trials, contraindications, or special clinical rationale.

Initial therapy requirements: Diagnosis identified on the form; AND documentation that the patient has either: (a) failed or is intolerant to a majority of preferred formulary alternatives (two or more in a class with at least two alternatives or one in a class with only one alternative) for at least six weeks (include medications tried, dates, and reasons for failure), OR (b) has a documented contraindication to listed formulary alternatives (include medication name(s) and contraindication), OR (c) has had or would reasonably be expected to have an adverse reaction to a majority of listed formulary agents (include medication name(s) and adverse reaction(s)), OR (d) has a clinical condition for which no listed formulary agent is appropriate per published guidelines (include clinical condition documentation); AND prescribed dose is within manufacturer's dosing guidelines or accepted compendia/current literature.

Step Therapy Requirements

Requirement	Form field / instruction
Documentation of medications tried	Form requests submission of medication(s) tried including names
Dates of trials	Form requests dates of trial(s) for each medication tried
Reason(s) for treatment failure	Form requests reason(s) for treatment failure(s) for each trial
Minimum trial duration for formulary alternatives	Form specifies failure/intolerance to preferred formulary alternatives for at least six weeks
Majority failure/intolerance definition	Form defines as failure/intolerance to a majority (two or more in a class with ≥2 alternatives or one in a class with only one alternative)