Pharmacy Prior Authorization Form
Customize your policy alerts
Sign up for all Highmark Blue Cross Blue Shield Wny policy alerts
Know when Highmark Blue Cross Blue Shield Wny releases new policies or updates existing guidance.
Monitor payer policy activity
A form and instructions governing prior authorization requests for pharmacy-covered medications for Highmark BCBS members in MMC, HARP, and Child Health Plus programs; affects prescribers, billing facilities, and pharmacies submitting PA requests.
No material clinical or coverage changes in this revision.
Coverage Determination Rules
Determination Requirements
Coverage determinations are made based on submitted medical necessity documentation and program eligibility.
See Instructions
See Medication information
See Prior Medications and Labs
See Instructions
Coverage determinations are made based on the medical necessity documentation submitted and the member's program eligibility. Payment is subject to current member eligibility, other insurance, and program restrictions. An approved prior authorization does not guarantee payment — all general conditions of Highmark BCBS remain applicable.
Required Codes and Tests
| HCPCS | HCPCS billing code required for medical injectable/oncology requests billed as a medical claim. |
| ICD | ICD/diagnosis code required for all requests. |
What Providers Must Do
Incomplete Form Sections
Complete this form in its entirety. Any incomplete sections will result in delayed processing and may lead to denial or processing delays.
- Complete all form sections — incomplete or missing information may delay review or result in denial.
Prior Authorization Submission Requirements
An ICD/diagnosis code is required for all requests. A HCPCS billing code is required for medical injectable/oncology requests billed as a medical claim. Include billing codes and complete medication information (drug name, strength, SIG). If the billing facility differs from the requesting physician, complete billing facility information.
- Provide ICD/diagnosis code for all requests.
- Provide HCPCS billing code for medical injectable/oncology requests billed to medical claims.
- Include drug name, strength, SIG (dose, frequency, duration).
- Complete billing facility information if different from requesting physician.
Prior Medication Trials
Document prior medication trials and provide details of prior drug use. Indicate whether the member tried other medications, list drug name(s), strength, date range of use, and SIG. Supporting documentation may be requested.
- If Yes: list prior medications, date ranges, SIG, and clinical outcome (adverse reaction, inadequate response, other).
- If No: explain why alternative therapies were not tried.
Providers May Be Asked to Provide Supporting Documentation
You may be asked to provide supporting documentation to substantiate the request. Examples include copies of medical records, office notes, diagnostic studies/lab results, and completed FDA MedWatch forms. Fax all required information to 844-490-4877 and allow at least 24 hours for review. For pharmacy prior authorization questions call 866-231-0847.
- Possible requested documentation: copies of medical records, office notes, completed FDA MedWatch form, recent labs and diagnostic test results (within 30 days).
- Fax documentation to 844-490-4877.
- Pharmacy prior auth questions: 866-231-0847.
Policy Context
This administrative prior authorization form is used for pharmacy-covered medications for members in the Medicaid Managed Care (MMC), HARP, and Child Health Plus programs administered by Highmark BCBS in partnership with Wellpoint companies. It collects member, medication, prescriber, billing facility, and pharmacy information to document medical necessity, prior medication trials, adverse reactions or inadequate responses, and relevant diagnostic/lab tests.
Complete the form in its entirety; any incomplete sections will result in delayed processing. The form requires an ICD/diagnosis code for all requests and, for medical injectable or oncology claims billed as a medical claim, a HCPCS billing code. Provide prior medication history including names, dates of use, and SIG when applicable; supporting documentation may be requested.
Submit the completed form and any supporting documentation by fax to 844-490-4877. Allow at least 24 hours for review. If you have questions, contact Highmark BCBS at 866-231-0847. While awaiting the outcome, the pharmacy may dispense up to a 72-hour supply.
Key Definitions
Prior Medication Trials
| Drug name and strength | Date range of use | SIG (dose and frequency) | Supporting documentation |
|---|---|---|---|
| Provide each prior medication tried for this condition, including the exact drug name and strength. | |||
| List the start and end dates (or ongoing) for each prior medication trial. | |||
| Provide the SIG: dose, frequency, and duration used during the trial. | |||
| May be requested: copies of medical records, office notes, and completed FDA MedWatch forms. |
Administration Location
Specify administration site and member residence
Indicate the administration site and the member’s place of residence on the form by selecting the appropriate option (Home, Office, Outpatient facility) and the member residence (Home or Nursing facility).
- Select administration site: Home, Office, or Outpatient facility.
- Select member's place of residence: Home or Nursing facility.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.