CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Prior authorization form for metformin solution (Riomet)

A payer-specific prior authorization request form and instructions for prescribing metformin solution (Riomet/metformin solution) describing required provider and clinical information to obtain prior authorization from OptumRx for Blue Cross Blue Shield - South Carolina members.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina (managed by OptumRx)

PolicyPrior authorization form for metformin solution (Riomet)

Policy CodePolicy N/A

Change TypeAdministrative form / submission instructions

Effective Date

Next Review Date

Key ActionComplete and submit the two-page prior authorization form with required clinical documentation and prescriber signature to OptumRx via fax (844-403-1029) or CoverMyMeds.

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Form pages

MultipleClinical sections required

844-403-1029Fax for submission

CoverMyMedsElectronic submission

Policy summary

This is a payer-specific prior authorization request form for metformin solution (Riomet) used by OptumRx on behalf of Blue Cross Blue Shield - South Carolina. The form is labeled as the metformin solution Prior Authorization Request Form and references Riomet/Metformin Solution.

The form is a two-page request with required provider and clinical information to obtain prior authorization, including diagnosis selection and ICD-10 code, documentation of trials/failures or intolerances to formulary alternatives, contraindications or adverse reactions, dosing justification, and a prescriber signature and date.

Operational highlights: the form is intended for submission to OptumRx (it may be faxed to 844-403-1029) and may be submitted electronically via CoverMyMeds for OptumRx; it is designed as a concise prior authorization form for this specific product and use.

Key Details

PayerOptumRx for Blue Cross Blue Shield - South Carolina

SubjectPrior authorization form for metformin solution (Riomet)

Scope summaryPayer-specific prior authorization request form and instructions for prescribing metformin solution describing required provider and clinical information to obtain prior authorization from OptumRx for BCBS-SC members.

Form pages1

Fax for submission844-403-1029

StatusCURRENT

Form completion & submission instructions

Operational / Submission Requirements

Form completion and supporting documentation requirements:

ALL of the following

Provider information must be completed (Member name, Provider name, Insurance ID#, NPI#, specialty, DOB, office phone/fax/address).
Medication information must be completed (medication name, strength, dosage form, directions for use).
Clinical information and attachments: Clinical information section must be completed and any required supporting documentation attached; request may be denied unless all required information is received.
This request may be denied unless all required information is received.
Fax submission: Form may be faxed to 844-403-1029.
Electronic submission via CoverMyMeds: OptumRx has partnered with CoverMyMeds for electronic prior authorization submissions at gocovermymeds.com/OptumRx.

Prior Authorization

Submit completed prior authorization form

Providers must complete and submit the two-page prior authorization form with required clinical documentation (diagnosis, trials/failures, contraindications, adverse reactions, dosing justification) and prescriber signature to OptumRx.

Fax: 844-403-1029
CoverMyMeds: gocovermymeds.com/OptumRx

Documentation Required

Document trials, contraindications, adverse reactions

Attach documentation of 90-day trials and failures or intolerances to formulary alternatives, or documentation of contraindications or adverse reactions, or a statement that no appropriate formulary agent exists per guidelines.

Include medication name(s), dates of trial(s), and reason(s) for treatment failure or intolerance
If documenting contraindication or adverse reaction, include medication name(s) and the contraindication or adverse reaction details

Denial Risk

Incomplete form may lead to denial

Requests may be denied unless all required information requested on the form and any supporting documentation are received.

Billing Rule

Use CoverMyMeds electronic submission (optional)

Providers may submit prior authorization requests electronically via CoverMyMeds; this service is provided in partnership with OptumRx and can often deliver real-time determinations.

CoverMyMeds: gocovermymeds.com/OptumRx

Policy Summary

PayerBlue Cross Blue Shield - South Carolina (managed by OptumRx)

PolicyPrior authorization form for metformin solution (Riomet)

Policy CodePolicy N/A

Change TypeAdministrative form / submission instructions

Effective Date

Next Review Date

Key ActionComplete and submit the two-page prior authorization form with required clinical documentation and prescriber signature to OptumRx via fax (844-403-1029) or CoverMyMeds.

On This Page

OpenPayer

Prior authorization form for metformin solution (Riomet)

Policy summary

Clinical requirements for prior authorization

Form completion & submission instructions

Requested diagnosis coding

Key terms

Document changes