CurrentHighmark Blueshield NenyPolicy N/A

Medication Prior Authorization Form - Coverage Criteria

Form and instructions to request prior authorization for prescription medications for Highmark members; used by prescribing providers to submit clinical and administrative information required for authorization decisions.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedication Prior Authorization Form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a separate completed prior authorization form for each medication and fax to 1-866-240-8123 or mail to the address provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-866-240-8123fax number for submission

1form to be submitted per medication

Includes checklisttherapies listed for failure documentation

Coverage Criteria

Authorization criteria

Coverage is considered when required documentation and criteria are provided.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Submission completeness: Form is fully completed for the requested medication with member and provider information, drug name/strength/quantity/day supply, directions, diagnosis/ICD-10 codes, and signature

Submit a separate form per medication; fax to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222; print/type or write legibly in blue or black ink

Clinical justification: Provide clinical information including whether induction dosing is required; if currently on therapy, provide documentation of disease stability or improvement; document prior therapeutic failures by selecting applicable agents from the checklist or listing others

Include member weight with unit (lb or kg) for dosing calculations

Authorization does not guarantee payment and payment is subject to member eligibility. Providers must submit a separate completed prior authorization form for each medication; forms and all clinical documentation should be faxed to 1-866-240-8123 or mailed to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. Incomplete submissions or missing clinical information may result in denial or delayed processing.

Coding & Supply

Requested Day Supply

Options30 days; 90 days; other (blank option on form)

Member weight

Required informationProvide member weight and include unit of measure (for example, lb or kg)

Induction dosing

Induction dosing questionForm asks: 'Does the member require induction dosing?' with options Yes or No

If YesProvider must indicate specifics of induction dosing on the form (space provided for details)

Related documentationAttach clinical documentation of induction dosing if applicable as part of required supporting materials

Provider Submission & Documentation Requirements

Denial Risk

Incomplete submission risk

Incomplete or missing information on the prior authorization form or absent supporting clinical documentation may result in denial or processing delays. Payment remains subject to member eligibility and benefits; authorization does not guarantee payment.

Ensure all fields on the form are complete and legible.
Attach all required clinical records (see documentation callout).
Allow adequate time for review — incomplete submissions will be returned or denied.

Documentation Required

Administrative documentation required

Provide complete administrative/provider information with the submission. The prescribing physician (PCP or Specialist) should, in most cases, complete the form.

Physician name, NPI, address (required for physician notification), phone and fax.
Physician signature and date.
Member identifying information (name, date of birth, member ID) and prescriber contact details.
Submit a separate completed prior authorization form for each medication.

Step Therapy

Prior therapy / step therapy documentation

Document prior therapy and step-therapy history demonstrating therapeutic failure, intolerance, or contraindication to applicable conventional therapies as required.

List all prior therapies tried and the reason for failure (e.g., lack of efficacy, adverse reaction, intolerance).
Common therapies to document include methotrexate, leflunomide, sulfasalazine, cyclosporine, hydroxychloroquine, phototherapy (PUVA/UVB), azathioprine, NSAIDs, local glucocorticoid injection, mercaptopurine, systemic corticosteroids (e.g., prednisone), and others as clinically relevant.
Include dates/duration of prior therapies and any supporting clinical notes or lab results.

Background

This form is used to request prior authorization for specialty and disease-modifying medications typically prescribed by specialists (for example, rheumatologists, dermatologists, ophthalmologists, and immunologists). It collects clinical details needed for authorization decisions, including prior therapy history (step-therapy items), whether induction dosing is required, current therapy status and response, diagnosis/ICD-10 code(s), and member weight for dose calculations. The prescribing physician should, in most cases, complete the form and provide their full address for notification.