CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Olux-E Prior Authorization Request Form — Coverage Criteria

This document is the payer-specific prior authorization form and instructions used by providers to request coverage for Olux-E (topical medication) for Blue Cross Blue Shield - South Carolina members. It governs what information must be submitted to obtain prior authorization.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyOlux-E Prior Authorization Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form (fax 844-403-1029 or via CoverMyMeds) with diagnosis, prior-trial documentation or contraindications, dosing, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

844-403-1029fax

CoverMyMedsonline portal

855-811-2218support

Coverage Criteria

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Initial Therapy

Covered when ALL of the following are met

Initial Authorization: 1) Prescriber documents a diagnosis (e.g., treatment of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses) with ICD-10 code; 2) Medication information (name, strength, dosage form, directions for use) is provided; 3) Patient has had trial and failure or intolerance to a majority of preferred formulary/preferred drug list alternatives OR has a documented contraindication to those alternatives OR has had an adverse reaction to or be reasonably expected to have an adverse reaction to a majority of those agents OR there is no listed formulary agent for the clinical condition (documentation required for any of these); 4) The drug is prescribed within the manufacturer's published dosing guidelines or dosing guidelines found in accepted compendia/current literature; 5) Prescriber's signature and date are provided.majority = two or more in a class with at least two alternatives or one if only one alternative exists

Documentation of trials, contraindications, or adverse reactions must include medication names, dates, and reasons for failure/intolerance; see form for required fields.

Initial Therapy (Olux-E)

Initial approval requires documented trials or contraindications to formulary alternatives and dosing within guidelines.

Initial drug-specific: Provider must document medication details (name, strength, dosage form, directions), the clinical diagnosis with ICD-10 code, and one of the following: (a) trial and failure or intolerance to a majority of preferred formulary/preferred drug list alternatives (see definition) with documentation of medication(s) tried, dates, and reason(s) for failure; OR (b) documented contraindication(s) to the listed formulary alternatives with documentation of medication name(s) and contraindication(s); OR (c) documented adverse reaction(s) to or reasonable expectation of adverse reaction(s) to a majority of listed formulary agents with documentation of medication name(s) and reaction(s); OR (d) documentation that no listed formulary agent exists for the condition based on published guidelines or literature. In all cases, the prescribed dose must fall within the manufacturer's published dosing guidelines or accepted compendia, and the prescriber must sign and date the form.

Include dates and reasons for trial failures or details of contraindications/adverse reactions as applicable.

Step Therapy / Prior Trials

Required documentation
Documentation must include medication name(s) of prior formulary alternatives tried	Dates of each trial	Reason for treatment failure or intolerance (including adverse reactions)
If contraindication: medication name(s) and documented contraindication	If adverse reaction: medication name(s) and description of adverse reaction	If no listed formulary agent exists: documentation of clinical condition and supporting literature/guidelines

Diagnosis & Coding

Diagnosis codes (provider entered)ICD-10

ICD-10 Code

field to be provided by prescriber for diagnosis

Prior trial count (inv-05)

Prior trial count requirementTwo or more in a class with at least two alternatives, or one if only one alternative exists (provider must document medications tried, dates, and reasons for failure/intolerance).

Documentation neededSubmit documentation of medication(s) tried, dates of trial(s), and reason(s) for treatment failure(s).

Applies toPreferred formulary/preferred drug list alternatives for the given diagnosis (example: Clobetasol propionate foam 0.05%).

Provider Actions & Submission Instructions

Prior Authorization

Prior Authorization Submission

Prior authorization required using the Olux-E® Prior Authorization Request Form. Fax completed form to 844-403-1029 or submit via the CoverMyMeds portal. Include diagnosis, trial/failure documentation, medication details, and complete provider/member information.

Fax: 844-403-1029
Or submit via CoverMyMeds portal
Include diagnosis and ICD-10 code
Include medication name, strength, dosage form, directions
Include provider and member information (NPI, insurance ID, contact info)

Step Therapy

Step Therapy / Prior Trials

Requires documentation of trial and failure or intolerance to a majority of preferred formulary alternatives. "Majority" is defined as two or more agents in a class when at least two alternatives exist, or one agent when only one exists. Provide medications tried, dates of trials, and specific reasons for failure or intolerance.

Document medications tried and dates of trial(s)
Provide reason(s) for treatment failure or intolerance
If contraindication exists, provide documentation of contraindication

Documentation Required

Required Documentation & Incomplete Submission Risk

Submit the completed prior authorization form with all required clinical and administrative information. Incomplete requests may be denied unless all required information is received.

Required: provider and member information, prescriber signature and date
Required: medication name, strength, dosage form, directions for use
Required: diagnosis and ICD-10 code
Required: documentation of prior trials, dates, and reasons for failure/intolerance
Risk: Request may be denied if information is missing

Definitions

Majority of preferred formulary alternatives (inv-11)

Definition of majority of preferred formulary alternativesMajority defined as two or more in a class with at least two alternatives, or one in a class with only one alternative.

Evidence requiredDocumentation that the patient trialed and had failure or intolerance to the majority of preferred formulary alternatives, with medication names, dates, and reasons for failure/intolerance.

ExamplesForm lists example agent: Clobetasol propionate foam 0.05% to illustrate a formulary alternative class member.

Background

Olux-E is indicated on the form for the treatment of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses. The form requires the prescriber to provide a diagnosis and corresponding ICD-10 code, document whether the patient has had trials and failures or intolerance to a majority of preferred formulary alternatives (defined as two or more in a class with at least two alternatives or one if only one alternative exists), or to document contraindications or adverse reactions to those agents, or that no listed formulary agent exists for the condition. The form also asks that dosing be within the manufacturer's published guidelines or accepted compendia.