CurrentHighmark Blueshield NenyPolicy MM-056 (R10-24)

PRESCRIPTION DRUG MEDICATION REQUEST FORM

This document is a provider-facing prescription drug medication request form and instructions for submission to Highmark BlueShield (fax/mail). It outlines required patient, clinical, and physician information, request types, prior authorization and non-formulary requirements, MRXC managed-drug categories, and submission procedures.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPRESCRIPTION DRUG MEDICATION REQUEST FORM

Policy CodePolicy MM-056 (R10-24)

Change TypeInformational

Effective Date

Next Review Date

Key ActionProviders must complete all fields on a separate form for each medication, include required clinical documentation, provide physician address for notification, and fax to 1-866-240-8123 or mail to Clinical Services, Pittsburgh.

POLICY UPDATE CHANGES

No material clinical/coverage changes reported.

1Form per medication required

2+Formulary trials usually required for non-formulary

Policy overview

Policy MM-056 (R10-24) — Prescription Drug Medication Request Form (Highmark) is a standardized provider-facing form and instruction set used to collect patient, clinical medication, and prescriber information needed to process formulary exceptions, prior authorizations, tiering exceptions, and appeals.

This form must be completed and submitted by the prescribing provider (PCP or specialist) or their staff; a separate form is required for each medication. Follow the form completion and submission instructions (complete all fields, provide physician address for notification) and fax the completed form and clinical documentation to 1-866-240-8123 or mail to Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.

PolicyPrescription Drug Medication Request Form (Highmark)

Policy NumberMM-056 (R10-24)

PayerHighmark Blueshield Neny

StatusCURRENT

Effective Date

Next Review

ScopeProvider-facing prescription drug medication request form and instructions for submission to Highmark BlueShield (fax/mail); outlines required patient, clinical, and physician information, request types, prior authorization and non-formulary requirements, MRXC managed-drug categories, and submission procedures.

Form completion, submission, and documentation requirements

Form completion and submission requirements

Form must be completed and submitted with required documentation:

ALL of the following

Submit a separate form for each medication
Complete ALL information on the form
Provide physician address (required for physician notification)
Fax the completed form and all clinical documentation to 1-866-240-8123 OR mail to Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222

Documentation Required

Complete and submit form per instructions

Providers must complete all fields on a separate form for each medication, include required clinical documentation, and provide physician address for notification; fax to 1-866-240-8123 or mail to Clinical Services, Pittsburgh.

Fax: 1-866-240-8123
Mail: Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222

Documentation Required

Non-formulary trial requirement

For most non-formulary products, provide documentation of trials of at least two formulary products demonstrating failure.

Prior Authorization

Prior authorization requirements

Certain drug categories require prior authorization; when requested, include diagnosis and supporting clinical documentation as specified (e.g., immunosuppressants require transplant documentation).

Prior authorization, MRXC management, and commonly managed categories

Prior authorization / MRXC / Medicare-specific

Categories commonly requiring prior authorization or MRXC management

Common PA/MRXC categories

Agents used for fibromyalgia (examples given: Cymbalta, Lyrica, Savella)
Miscellaneous items including contraceptives (require statement of medical necessity only), Provigil, immediate release fentanyl products
Testosterone therapies
Specialty drugs (examples: Enbrel; Sutent; Tracleer)
Medications used to treat migraines (examples: Amerge; Imitrex; Maxalt) — MRXC managed
Leukotriene modifiers (Singulair, Accolate, Zyflo) — MRXC managed
Medications for onychomycosis (Lamisil, Sporanox) — MRXC managed
Pain management agents (examples: OxyContin, Opana ER) — MRXC managed
Immunosuppressants: require diagnosis and/or documentation of Medicare-approved organ transplant (Medicare formularies)
Intravenous immune globulins: require diagnosis and place of service (Medicare formularies)
Methotrexate (oral): require diagnosis (Medicare formularies)

MRXC is defined as the Managed Prescription Drug Coverage program that includes specific drug therapy categories with set thresholds or limits and uses criteria established by the Pharmacy and Therapeutics Committee to assess requests for additional quantities.

The MRXC program manages categories such as medications for migraines, leukotriene modifiers, onychomycosis treatments, and certain pain management agents; these categories have quantity or threshold rules set by the Pharmacy and Therapeutics Committee.

Note: Medicare-approved formularies may impose additional documentation or requirements for some categories (for example, immunosuppressants require documentation of a Medicare-approved organ transplant; IV immune globulins require diagnosis and place of service; oral methotrexate requires diagnosis).

Non-formulary requests and required trials

Non-formulary requests

Non-formulary coverage documentation requirements

ALL of the following

Documentation of a trial of at least two formulary products (for most products)

Operational note: Providers must complete all fields on a separate form for each medication and include required clinical documentation and physician address for notification when submitting requests.

Documentation of formulary product trials is typically required for non-formulary requests — generally a trial of at least two formulary products demonstrating failure or intolerance should be included.

Include supporting clinical notes that document treatment failure or intolerance and any other required information referenced for specific drug categories (for example, transplant documentation for immunosuppressants when applicable).

Form-specific notes and quick stats

Form per medication required1

Formulary trials usually required for non-formulary2+

The MRXC program manages specific drug categories with quantity or threshold rules established by the Pharmacy and Therapeutics Committee; these managed categories include therapies such as migraine agents, leukotriene modifiers, onychomycosis treatments, and certain pain management medications.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPRESCRIPTION DRUG MEDICATION REQUEST FORM

Policy CodePolicy MM-056 (R10-24)

Change TypeInformational

Effective Date

Next Review Date

On This Page

OpenPayer

PRESCRIPTION DRUG MEDICATION REQUEST FORM

Policy overview

Form completion, submission, and documentation requirements

Prior authorization, MRXC management, and commonly managed categories

Non-formulary requests and required trials

Form-specific notes and quick stats

Definitions

Revision history