CurrentPremera BluecrossPolicy N/A

Pharmacy Formulary Exception Request Form — Coverage Criteria

Form used by providers to request coverage for non-formulary medications (including brand name contraceptives) and to request expedited review for urgent cases; applies to Premera Bluecross members and their prescribing providers.

Policy Summary

PayerPremera Bluecross

PolicyPharmacy Formulary Exception Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed fax-back form with medication details, diagnosis (ICD-10), prior medications and supporting chart notes; check expedited review box for exigent circumstances.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24hexpedited review determination timeframe

1-888-260-9836fax submissions

1-888-261-1756Pharmacy Services phone

patient & prescriberrequired fields

Coverage Criteria

Form submission criteria

Coverage may be requested when the provider documents ALL of the following on the form:

Form completion: Patient and prescriber contact information completed

See form header for required demographic and contact fields

Medication details: Medication name and strength; length of therapy with start and end dates; quantity per month provided

Use fields: Medication (Drug Name and Strength), Length of Therapy, start date, end date, Quantity/Month

Diagnosis and coding: Diagnosis and ICD-10 code provided

Use Diagnosis and ICD-10 fields on the form

Policy Summary

PayerPremera Bluecross

PolicyPharmacy Formulary Exception Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed fax-back form with medication details, diagnosis (ICD-10), prior medications and supporting chart notes; check expedited review box for exigent circumstances.

SourceLink

On This Page

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Provider Submission Requirements

Prior Authorization

Form elements required for exception review

Complete and accurate completion of the pharmacy formulary exception request form is required for exception review. The form must include medication and diagnosis information (drug name and strength, length of therapy with start and end dates, quantity per month, diagnosis and ICD-10 code) and the clinical rationale for the non-formulary request. For brand name contraceptives, a box certifying medical necessity must be checked when applicable.

Medication (Drug Name and Strength)
Length of Therapy — include start date and end date
Quantity/Month
Diagnosis and ICD-10 code
Clinical rationale for the non-formulary request
List of prior medications with reason therapy stopped and lengths of therapy (include start and end dates)
For brand name contraceptives: check the medical necessity box if applicable

Denial Risk

Incomplete submission risk

Incomplete or missing information may delay processing or result in an adverse determination for insufficient information. Ensure all required fields are completed and relevant chart notes are attached; incomplete submissions risk denial or request for additional information.

Fax completed form and supporting documentation to Pharmacy Services: 1-888-260-9836
Phone inquiries: 1-888-261-1756

Documentation Required

Prior medication history — include list of prior medications and reasons therapy stopped

Provide a complete prior medication history: list all prior medications tried for the same indication, the length of therapy for each (start and end dates), and the specific reason therapy was stopped (e.g., lack of efficacy, adverse effect, intolerance, contraindication). Include any other pertinent clinical rationale and attach relevant chart notes. Do not send DNA or other genetic samples or results unless specifically requested.

List prior medications
Reason therapy stopped for each prior medication
Length of therapy for each prior medication — start and end dates
Other pertinent clinical rationale and supporting chart notes

Background

This fax-back form is an administrative tool to document medical necessity for non-formulary drugs, capture the clinical rationale and prior therapy history, and record requests for expedited review when appropriate. Providers must complete patient and prescriber details, medication name and strength, therapy start and end dates, quantity per month, diagnosis and ICD-10 code, and the clinical rationale including prior medications and reasons therapy stopped. For brand name contraceptives, check the medical necessity certification box when applicable. If an exigent circumstance is claimed, check the expedited review box and sign to request a 24-hour determination.

Definitions

Exigent circumstance

DefinitionExigent circumstance: Applies to formulary exception requests when a patient is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function.

How to request expedited reviewPrescriber must check the expedited review box and sign the form to certify the request is due to an exigent circumstance.

Standard vs expedited timingIf the box is checked and signed, the request will be processed as expedited; otherwise it will not be handled as expedited.

Purpose of expedited requestUsed when 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.

Required prescriber actionPrescriber's signature and date are required on the form for the expedited (exigent) request to be valid.

OpenPayer

Pharmacy Formulary Exception Request Form — Coverage Criteria

Coverage Criteria

Diagnosis & Codes

Provider Submission Requirements

Background

Definitions