CurrentPremera BluecrossPolicy N/A

Pharmacy services prior authorization request form

This is a pharmacy prior authorization (PA) request form for Premera Blue Cross used by prescribers to request coverage exceptions, prior authorizations, quantity-limit exceptions, off-label use approvals, expedited reviews, and certification of medical necessity (including brand contraceptives). It collects member, prescriber, medication/diagnosis, clinical rationale, and signature information.

Policy Summary

PayerPremera Bluecross

PolicyPharmacy services prior authorization request form

Policy CodePolicy N/A

Change TypeOperational form (no coverage change)

Effective Date

Next Review Date

Key ActionProvider must complete and sign the form, include member and prescriber details, medication name/strength, ICD-10 diagnosis, quantity, start date, expected length of therapy, drug allergies, and attach chart notes/supporting documentation as required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this document is an operational prior authorization request form (no policy coverage changes indicated).

1Form pages

24hExpedited review timeframe

Policy overview

This form is a pharmacy prior authorization (PA) request form used by Premera Blue Cross to request coverage exceptions, prior authorizations, quantity-limit exceptions, off-label use approvals, expedited reviews, and certification of medical necessity (including brand contraceptives).

It collects member and prescriber details, including contact information and prescriber signature, as well as medication and diagnosis information (medication name/strength, ICD-10 diagnosis, quantity, start date, expected length of therapy, and drug allergies).

Submission criteria and request types

Types of Requests / Criteria for Submission

Requests may include any of the following; prescriber must provide supporting documentation and chart notes where indicated.

Member needs a drug that is not on the plan's list of covered drugs.

Prescriber must provide statement supporting exception request; chart notes required.

Requesting an exception to the requirement that member tries another drug before member gets the drug prescribed (step therapy exception).

Prescriber must provide statement supporting exception request; chart notes required.

Requesting an exception to the plan's limit on the allowed amount (quantity limit) a member can receive.

Prescriber must provide statement supporting exception request; chart notes required.

Requesting an exception to use a drug or biologic agent for an off-label indication.

Prescriber MUST provide a statement supporting the exception request; chart notes required.

Clinical Rationale Options (select all that apply)

Prescriber must select applicable rationale(s) and provide required explanation details.

Alternate drug(s) contraindicated or previously tried, but with adverse outcome (e.g., toxicity, allergy, or therapeutic failure).

Specify: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s). Chart notes required.

Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change.

Specify anticipated significant adverse clinical outcome. Chart notes required.

Medical need for different and/or higher dosage.

Specify dosage form(s) and/or dosage(s) tried; explain medical reason. Chart notes required.

Off-label use is supported by medical compendia, scientific evidence, or approved via Emergency Use Authorization.

Explain and provide supporting documentation. Chart notes required.

Expedited review and special certifications

Expedited Review (24-hour determination)

Expedited review is available when check box is selected and prescriber signs certifying exigent circumstance.

Box for Request for Expedited Review is checked.

Prescriber's signature is included certifying that the 72-hour standard review time may seriously jeopardize the life or health of the member or the member's ability to regain maximum function.

Medical Necessity for Brand Name Contraceptives

Certification required if brand name contraceptive is claimed medically necessary.

Box certifying that a brand name contraceptive is medically necessary is checked.

What providers must do

Prior Authorization

Submit completed PA form

Provider must complete and sign the form, include member and prescriber details, medication name/strength, ICD-10 diagnosis, quantity, start date, expected length of therapy, drug allergies, and attach chart notes/supporting documentation as required.

Member/prescriber details
Medication name and strength
ICD-10 diagnosis
Quantity
Start date / New script or date therapy initiated
Expected length of therapy
Drug allergies
Attach chart notes/supporting documentation as required

Prior Authorization

Fax submission

Return the completed form by fax to Pharmacy Services; questions may be directed by phone.

Fax: 1-888-260-9836
Phone (questions): 1-888-261-1756

Prior Authorization

Expedited request certification

For expedited (24-hour) review, prescriber must check the expedited box and sign certifying an exigent circumstance; otherwise standard review timelines apply.

Check the Request for Expedited Review box
Prescriber's signature certifies exigent circumstance
Expedited determination timeframe: 24 hours (request not expedited unless box is checked and signature included)

Documentation Required

Chart notes required

Chart notes are required to support exception requests including step therapy, quantity limit, non-formulary, and off‑label use requests.

Step therapy exceptions (require prescriber statement and chart notes)
Quantity limit exceptions (require prescriber statement and chart notes)
Non-formulary / drug not on plan's list (require prescriber statement and chart notes)
Off-label use justifications (require prescriber statement and chart notes)

Policy Summary

PayerPremera Bluecross

PolicyPharmacy services prior authorization request form

Policy CodePolicy N/A

Change TypeOperational form (no coverage change)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Pharmacy services prior authorization request form

Policy overview

Submission criteria and request types

Expedited review and special certifications

What providers must do

Definitions