CurrentHighmark DelawarePolicy N/A

Prescription Drug Medication Request Form — Coverage Criteria

Standardized form and instructions for providers to request coverage, prior authorization, tiering or formulary exceptions, and appeals for prescription medications for Highmark Delaware members. Applies to providers submitting drug coverage requests for commercial and Medicare lines of business.

Policy Summary

PayerHighmark Delaware

PolicyPrescription Drug Medication Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax a separate, fully completed form with physician address, signature, and supporting clinical documentation to 1-866-240-8123 for each medication request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-866-240-8123fax submissions

1one drug per form

yesseparate form required

2non-formulary trial

Coverage and Documentation Criteria

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General coverage and documentation criteria

Covered when ALL of the following are met:

Submission requirements: Submit a separate, fully completed form for each medication; complete all required patient and prescriber fields, include physician address and signature; fax the completed form and all clinical documentation to 1-866-240-8123 or mail to Clinical Services, 120 Fifth Avenue, MC P4207, Pittsburgh, PA 15222.

Forms must be legible; use one form per drug.

Category-specific documentation

Non-formulary requests: Document trial and failure of at least two formulary products.
Immunosuppressants / Transplant-related requests: Provide diagnosis and documentation of Medicare‑approved organ transplant and name of carrier who paid for most recent transplant, type and date of transplant.
Include transplant payer information as requested on the form.
MRXC-managed therapies: Supply information to support additional quantities or program thresholds per the MRXC program and Pharmacy & Therapeutics Committee criteria.
Specific products and limits are managed under the MRXC program.

Provider Submission, Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for multiple drug classes and specific products. Providers must obtain PA before dispensing or claims may be denied or delayed. Common categories requiring PA include specialty drugs, testosterone therapies, select pain agents, certain migraine medications, fibromyalgia agents, and other miscellaneous products listed below. Contraceptives require a statement of medical necessity only.

Fax PA requests and all supporting clinical documentation to 1-866-240-8123
For mail submission, send to Clinical Services, 120 Fifth Avenue, MC P4207, Pittsburgh, PA 15222
See Highmark Medicare-approved formulary and Authorization Requirements pages for full, current lists

Documentation Required

MRXC Managed Therapy

The MRXC program manages specific therapy categories with quantity thresholds and limits. Requests for quantities above standard thresholds must include documentation that meets MRXC criteria and the Pharmacy & Therapeutics Committee guidelines. Examples of MRXC-managed categories include migraine therapies, onychomycosis treatments, leukotriene modifiers, and selected pain management products.

Include indication, previous therapies, and rationale for doses/quantities exceeding standard thresholds
Document trial/failure of formulary alternatives when applicable

Documentation Required

Submission and Required Documentation

Complete and submit the Highmark Prescription Drug Medication Request Form for each medication request. The prescribing physician should, in most cases, complete the form. Provide the physician's full address and signature as these are required for physician notification. Fax the completed form and ALL clinical documentation to 1-866-240-8123 or mail to Clinical Services at the address below. Use a separate form for each drug.

Print, type or write legibly in blue or black ink
Include subscriber ID, patient demographics, diagnosis, drug name/strength/quantity, and physician NPI or Tax ID
Attach all supporting clinical documentation (labs, prior therapy records, transplant payer information if applicable)

Documentation Required

Minimum Clinical Documentation Requirements

Minimum clinical documentation is required for certain categories. Non-formulary requests typically require documentation of trials of at least two formulary products. Immunosuppressant requests require documentation of a Medicare-approved organ transplant diagnosis and payer. Methotrexate (oral) and intravenous immune globulin requests require diagnosis (and place of service for IVIG). Provide specific failure/contraindication notes for each prior agent trial.

For non-formulary: list prior formulary agents, doses, duration, and reason for discontinuation
For transplant-related immunosuppressants: include transplant type, date, and payer information
For MRXC overrides: document prior quantity trials and medical necessity for higher quantities

Denial Risk

Documentation-Triggered Denials

Incomplete or missing documentation can result in denial of the PA request or claim. Providers should ensure all required fields on the form are completed and that all requested attachments (trial documentation, transplant payer info, signatures) are included. Denials or delays are likely if PA or transplant-specific documentation is not provided.

Verify physician signature and address are present before submission
Ensure trial/failure evidence for required prior therapies is attached
Provide transplant payer and date when requesting transplant-related drugs to avoid denial

Step Therapy and Prior Trials

Requirement	Details
Provide prior trials/clinical justification on the form	Providers must complete all form fields and attach supporting clinical documentation when submitting a separate, fully completed form for each medication (see form instructions). For non-formulary requests, include documentation of trial of at least two formulary products.
MRXC may limit quantities per Pharmacy & Therapeutics criteria	The MRXC program manages specific drug therapy categories with set thresholds or limits; documentation may be required to justify quantities or to demonstrate trials consistent with Pharmacy & Therapeutics committee criteria.
Submission destination and format	Fax the completed form and clinical documentation to 1-866-240-8123 (or mail to Clinical Services in Pittsburgh) as instructed on the form; submit a separate form for each medication.

Policy Background and Scope

This form is used to request coverage, prior authorization, tiering or formulary exceptions, and appeals for prescription medications for Highmark Delaware members. It collects essential patient identifiers (subscriber ID, patient name, DOB, telephone, address), payer/coverage information, and the specific medication details including drug name, strength or dose, and requested quantity per month.

The form requires prescriber information including the physician name, NPI or Tax ID, phone, fax, full address and a physician signature. Request type (commercial, Medicare options, or transplant-related indicators) and the specific request action (e.g., prior authorization, non‑formulary, tiering exception, or appeal type) are documented on the form to direct processing.

Clinical justification fields capture the diagnosis and a history of prior therapies. For non‑formulary requests, the form requires documentation of failure or trial of other agents — typically trial documentation of at least two formulary products. For transplant‑related immunosuppressant requests, the form captures the type and date of most recent transplant and the carrier who paid for that transplant.

Providers must complete all requested fields and attach supporting clinical documentation (e.g., records of prior therapy failures, relevant diagnoses, or transplant documentation) when faxing the form. Each medication requires a separate, fully completed form; fax submissions are sent to 1-866-240-8123 (or mailed to Clinical Services in Pittsburgh) as specified in the instructions.

OpenPayer

Prescription Drug Medication Request Form — Coverage Criteria

Coverage and Documentation Criteria

Provider Submission, Authorization, and Documentation Requirements

Program Thresholds and Codes

Step Therapy and Prior Trials

Key Definitions

Policy Background and Scope