CurrentHighmark Blueshield NenyPolicy N/A

Prescription Drug Medication Request Form — Coverage Criteria and Submission Requirements

This document is the Highmark BlueShield NENY Prescription Drug Medication Request Form describing provider submission requirements for non-formulary, prior authorization, tiering exception and related prescription drug requests for members (including Medicare). It affects prescribers and their office staff who request coverage or exceptions for medications.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPrescription Drug Medication Request Form — Coverage Criteria and Submission Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a separate, fully completed form and all supporting clinical documentation (including diagnosis and place of service for IVIG) via fax to 1-866-240-8123 or by mail.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax 1-866-240-8123primary submission fax number

separate form per drugsubmission requirement

2 trialsnon-formulary trial expectation

Medicare includedMedicare references

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General Authorization Criteria

Requests are processed when required documentation and criteria are provided:

Required submission elements: Submit a separate, fully completed form for each medication including patient information, clinical medication information (drug name, strength, requested quantity, diagnosis), physician information (including NPI/Tax ID and signature), and supporting clinical documentation.

Submit via fax to 1-866-240-8123 or mail to Clinical Services in Pittsburgh.

Non-formulary medication requests are evaluated against formulary trial expectations. For most non-formulary products, the request should include documentation showing a trial of at least two formulary products. Failure to document these trials may result in denial of the non-formulary request.

Requests that do not include the required documentation of formulary trials or other specified clinical necessity are subject to denial as not medically necessary. Providers must document trials and failures of formulary alternatives (when required) to support coverage for non-formulary or higher-cost therapies.

Initial Therapy / Non-Formulary Requests

Non-Formulary Requests

Non-formulary requests are considered when the following expectations are met:

Non-formulary trial expectation: Documentation of a trial of at least two formulary products is required for most non-formulary products.2 formulary trials

Document clinical reason and outcome (failure/intolerance) for each formulary product tried.

Supporting clinical documentation: Provide diagnosis and any drug-specific documentation required by category (e.g., Medicare-approved organ transplant documentation for immunosuppressants; diagnosis and place of service for IVIG; diagnosis for oral methotrexate).

Follow MRXC and prior authorization documentation requirements where applicable.

MRXC / Prior Authorization: Requests for products or categories managed under MRXC or prior authorization programs must meet program-specific thresholds or criteria (as set by the Pharmacy & Therapeutics Committee) and may require step-therapy or quantity justification.

Examples of MRXC-managed categories include migraine therapies, leukotriene modifiers, onychomycosis agents, and certain pain management drugs.

Provider Submission & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain drugs and therapeutic categories. Examples include agents used for fibromyalgia (e.g., Cymbalta, Lyrica, Savella), miscellaneous items such as contraceptives (which require a statement of medical necessity only), Provigil, immediate‑release fentanyl products, testosterone therapies, and specialty drugs. Providers should verify current lists on the Highmark Provider Resource Center as categories may change.

Fax completed form and clinical documentation to 1-866-240-8123
Or mail to: Clinical Services, 120 Fifth Avenue, MC P4207, Pittsburgh, PA 15222

Step Therapy

MRXC Quantity Management

The MRXC program enforces quantity thresholds and limits for specific drug categories based on Pharmacy & Therapeutics criteria. Common categories managed under MRXC include medications for migraines, leukotriene modifiers (Singulair, Accolate, Zyflo), treatments for onychomycosis (Lamisil, Sporanox), and certain pain management agents (e.g., OxyContin, Opana ER). Requests for quantities above program thresholds will be reviewed against MRXC criteria; provide supporting clinical information to justify additional quantities.

MRXC thresholds and criteria are set by the Pharmacy & Therapeutics Committee
Program-managed categories are subject to change with new FDA approvals

Documentation Required

Submission & Documentation Requirements

Submit a separate, fully completed form for each medication. The prescribing physician should usually complete the form and include the physician address for notification. Fax the completed form and all clinical documentation to 1-866-240-8123 or mail to Clinical Services at the address above. Clinical documentation must include diagnosis and any relevant supporting records. For specific therapies include: diagnosis and documentation of Medicare‑approved organ transplant for immunosuppressants; diagnosis and place of service for intravenous immune globulins (IVIG); and diagnosis for oral methotrexate.

Complete ALL information on the form
Include diagnosis and place of service for IVIG
Include transplant documentation for immunosuppressants
Include diagnosis for oral methotrexate

Denial Risk

Non‑Formulary Trial Requirement

Non‑formulary requests generally require documentation of a trial of at least two formulary products. Failure to document trials of at least two formulary alternatives may result in denial of the non‑formulary request.

Document trials of at least two formulary products for most non‑formulary requests

Submission Contact & Coding Details

Submission contactmixed

1-866-240-8123

Fax number for prescription drug medication request form

MRXC program thresholds

AuthorityThresholds and limits are established by the Pharmacy and Therapeutics Committee and used by the MRXC program to assess requests for additional quantities.

ScopeApplies to specific drug therapy categories managed under the MRXC program (see managed categories).

Use for quantity requestsRequests for additional quantities are evaluated against MRXC-specific criteria as set by the Pharmacy & Therapeutics Committee.

Change noticeDrugs and therapeutic categories managed under MRXC are subject to change with new FDA approvals or Committee updates.

Step Therapy and Prior Authorization Programs

Program	Requirement	Examples / Managed Categories
MRXC (Managed Prescription Drug Coverage)	May require trials of formulary alternatives and enforces quantity thresholds or limits per criteria set by the Pharmacy & Therapeutics Committee; requests for additional quantities must meet MRXC criteria.	Migraines; Leukotriene modifiers (Singulair, Accolate, Zyflo); Onychomycosis (Lamisil, Sporanox); Pain management agents (OxyContin, Opana ER)
Prior Authorization	May require documentation of prior trials and clinical information (diagnosis, transplant documentation, place of service for certain therapies) before approving non‑formulary or higher‑cost therapies.	Drug categories and specific agents listed in the policy that require prior authorization (see MRXC-managed list and prior authorization section).

Quantity Management and Limits

MRXC-managed categories

MigrainesMedications used to treat migraines are managed under MRXC with set thresholds or limits.

Leukotriene modifiersSingulair, Accolate, and Zyflo are MRXC-managed; quantity limits apply per Committee criteria.

Onychomycosis agentsLamisil and Sporanox are managed under MRXC with specified thresholds or limits.

Pain management opioidsAgents such as OxyContin and Opana ER are MRXC-managed; quantity limits enforced.

Specialty categoriesImmunosuppressants and IVIG may require authorization and are subject to MRXC or Medicare formulary management where applicable.