CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Prior authorization form for prescription omega-3 products (Lovaza, Vascepa)

A prior authorization request form used by OptumRx/Blue Cross Blue Shield South Carolina for coverage decisions regarding Lovaza (omega-3-acid ethyl esters) and Vascepa. It collects provider, member, medication, and limited clinical information (not a full policy), and establishes that requests may be denied if required information is missing.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyPrior authorization form for prescription omega-3 products (Lovaza, Vascepa)

Policy CodePolicy N/A

Change TypeForm-only; no policy criteria changes

Effective Date

Next Review Date

Key ActionComplete and submit the prior authorization form with all required provider, medication, and clinical information; requests may be denied if required information is not received.

POLICY UPDATE CHANGES

No material clinical or coverage changes

1Key clinical threshold

2Core form sections (Provider, Medication, Clinical)

Coverage Summary

This document is a prior authorization request form for prescription omega-3 products (Lovaza, Vascepa) used by OptumRx and Blue Cross Blue Shield South Carolina. It is a form-only document that collects provider, member, medication, and limited clinical information and does not contain the full clinical coverage criteria or clinical justifications.

Prior Authorization Required Information

Form must be completed with ALL required items; request may be denied unless all required information is received.

Provider information completed including Member Name, Provider Name, Insurance ID#, NPI#, Specialty, Date of Birth, Office Phone, Street Address, Office Fax, City, State, ZIP
Required (see form).
Medication information completed including Medication Name, Strength, Dosage Form, Directions for Use
Required (see form).
Clinical triglyceride question: Clinical information completed answering whether patient has (or had prior to start of triglyceride-lowering drug) a triglyceride level >= 500 mg/dL (Yes/No)>= 500 mg/dL
Clinical threshold queried on the form.
Prescriber's signature and date
Required (see form).
Optional/Additional comments: other diagnoses, symptoms, medications tried/failed, and any information physician feels is important
Optional field on form.

Required Provider Actions & Submission Instructions

Prior Authorization

Submit completed prior authorization form

Complete and submit the prior authorization form with all required provider, medication, and clinical information so the request can be processed.

Documentation Required

Document triglyceride level

Indicate on the form whether the patient has (or prior to starting a triglyceride‑lowering drug had) a triglyceride level >= 500 mg/dL. Note: threshold = >= 500 mg/dL.

Billing Rule

Fax submission option

You may fax the completed form to 844-403-1029.

Denial Risk

Incomplete submissions may be denied

Requests may be denied if all required information on the form is not received; ensure all required provider, medication, and clinical fields are completed.

Background

This authorization request form is used by OptumRx in partnership with CoverMyMeds to collect the necessary information to process prior authorization for omega-3 prescription products (Lovaza, Vascepa). The form collects required Provider, Medication, and Clinical information, may be submitted via the CoverMyMeds service or fax (844-403-1029), and explicitly states that it is a form-only document and does not by itself state full coverage policy criteria or clinical justifications; requests may be denied if required information is missing.

Triglyceride level >= 500 mg/dL: a clinical threshold queried on the form to identify severe hypertriglyceridemia prior to initiating therapy.