CurrentHighmark Blueshield NenyPolicy MM-056 (R10-24)

Prescription Drug Medication Request Form / Prior Authorization and MRXC Requirements

Standard pharmacy prior authorization and medication request form and instructions used by Highmark for processing non-formulary, prior authorization, and Medicare-covered drug requests; intended for prescribing providers submitting requests for members in the Highmark service area.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPrescription Drug Medication Request Form / Prior Authorization and MRXC Requirements

Policy CodePolicy MM-056 (R10-24)

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax the completed form and all clinical documentation to 1-866-240-8123 (one form per medication).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form to submit per drug

1-866-240-8123fax number

≥2required formulary trials

MRXCMRXC program

Coverage and Authorization Criteria

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Coverage and Authorization Criteria

Coverage and authorization depend on meeting program-specific requirements and providing required documentation:

Submission requirements: Submit a separate, fully completed form for each medication including patient identification, diagnosis, drug name/strength/quantity, prescriber NPI/Tax ID and address, and prescriber signature; include all relevant clinical documentation and prior therapy information.

Supported by chunks 0 and 3

Non-formulary requests: For most non-formulary products, document trial of at least two formulary products.trial of at least two formulary products

chunk 5

Prior authorization categories: Certain drug classes require prior authorization; examples include agents used for fibromyalgia (e.g., Cymbalta, Lyrica, Savella), testosterone therapies, selected miscellaneous items (contraceptives require a medical necessity statement), specialty drugs (e.g., Enbrel, Sutent, Tracleer), and additional categories listed on Medicare-approved formularies (see immunosuppressants, methotrexate, IV immune globulins).

chunks 6 and 8

MRXC management: Drugs managed under the MRXC program are subject to specific thresholds/limits and criteria established by the Pharmacy and Therapeutics Committee; provide documentation to support requests for quantities beyond those thresholds.

chunk 7

Categories of drug management and the specific drugs or therapeutic classes subject to prior authorization or other utilization controls are maintained online and may change. For the most current and comprehensive lists, refer to the Highmark formularies and the Medicare‑approved formulary pages on the Highmark provider website.

Provider Submission and Authorization Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain drugs and therapeutic categories. Submit a separate prior authorization request for each medication and include all required clinical information to avoid delay.

Fax completed form and all clinical documentation to 1-866-240-8123 (submit each form separately).
Or mail to: Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.
For a complete list of services requiring authorization and additional guidance, visit: https://providers.highmark.com/claims-and-authorization/authorization-guidance/obtaining-authorizations

Step Therapy

MRXC Managed Therapy Thresholds

The MRXC managed prescription drug coverage program enforces specific thresholds and limits for certain drug categories. Requests for additional quantities must include documentation that supports need per MRXC criteria.

Include clinical rationale and prior therapy history when requesting quantities above standard thresholds.
MRXC categories and thresholds may change with new FDA approvals; check formulary resources for updates.

Denial Risk

Incomplete Submission Risks

Incomplete submissions will be delayed or may be rejected. Complete ALL information on the form and provide required clinical documentation. Use a separate form for each drug.

Failure to complete the form or to supply requested clinical documentation may result in denial or processing delays.
Do not submit multiple drugs on the same form; fax each form separately.

Documentation Required

Provider Submission Instructions

Fax the completed Prescription Drug Medication Request Form and include all supporting clinical documentation. The prescribing physician should complete the form and provide a physician address for notification.

Fax each form separately to 1-866-240-8123.
Or mail to: Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.
Ensure physician name, NPI or Tax ID (required), phone, fax, address, and signature with date are included.

Denial Risk

Denial Risk for Missing Formulary Trials

Non-formulary requests generally require documentation of trials of at least two formulary products. Failure to document such trials may result in denial.

When requesting non-formulary coverage, include documentation of trials and reasons for failure of at least two formulary alternatives.
If trials are not documented, the request may be denied.

Form Purpose and Scope

This medication request form is intended to capture sufficient information to support coverage decisions and prior authorization determinations. Complete a separate form for each medication and provide patient identifiers, prescriber name/address, NPI/Tax ID, drug name/strength/quantity, dosing and duration, clinical diagnosis, and relevant prior therapy information.

Include supporting clinical documentation demonstrating prior therapy and medical necessity per program requirements (for most non‑formulary requests document a trial of at least two formulary products), and any additional documentation specific to the drug category (for example, diagnosis and documentation of a Medicare‑approved organ transplant for immunosuppressants, diagnosis for oral methotrexate, or diagnosis and place of service for intravenous immune globulins).

Submit the completed form and all clinical documentation by fax to 1-866-240-8123 or by mail to Clinical Services, 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. Ensure all required fields are fully completed to avoid processing delays or potential denials.

Key Definitions

Specialty drugs — definition and examples

DefinitionSpecialty drugs are high-cost or complex medications often requiring prior authorization.

ExamplesEnbrel, Sutent, Tracleer (examples listed in policy).

ContextListed among common drug/therapeutic categories that require prior authorization per Highmark.

MRXC program

Program definitionMRXC is a Managed Prescription Drug Coverage program that includes coverage for specific drug therapy categories with set thresholds and limits, using criteria set by the Pharmacy and Therapeutics Committee to assess requests for additional quantities.

Managed categories (examples)Migraines (Amerge, Imitrex, Maxalt), Onychomycosis (Lamisil, Sporanox), Leukotriene modifiers (Singulair, Accolate, Zyflo), Pain management (OxyContin, Opana ER).

Documentation requirementRequests for quantities beyond MRXC thresholds must include supporting information as assessed by MRXC criteria.

Step Therapy and Quantity Requests

Requirement	Details
Follow MRXC program criteria
Drugs in MRXC categories are subject to set thresholds/limits; requests for quantities beyond those thresholds must include documentation supporting the need, as assessed using criteria set by the Pharmacy and Therapeutics Committee.
Managed MRXC categories (examples)
Medications managed under MRXC include migraine therapies (e.g., Amerge, Imitrex, Maxalt), onychomycosis agents (Lamisil, Sporanox), leukotriene modifiers (Singulair, Accolate, Zyflo), and certain pain management opioids (OxyContin, Opana ER).
How to request additional quantities
Provide supporting clinical documentation demonstrating medical necessity and why quantity beyond the MRXC threshold is required; submissions are evaluated against MRXC criteria established by the Pharmacy and Therapeutics Committee.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPrescription Drug Medication Request Form / Prior Authorization and MRXC Requirements

Policy CodePolicy MM-056 (R10-24)

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax the completed form and all clinical documentation to 1-866-240-8123 (one form per medication).

SourceLink

On This Page

OpenPayer

Prescription Drug Medication Request Form / Prior Authorization and MRXC Requirements

Coverage and Authorization Criteria

Formulary Trial Requirements

Provider Submission and Authorization Actions

Form Purpose and Scope

Key Definitions

Initial Therapy Requirements for Non-Formulary Agents

Step Therapy and Quantity Requests

Place of Service Requirements