"Prior Approval/Non-formulary Medication Request Form - Blue Cross Blue Shield of Western New York" - New York

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PRIOR APPROVAL/NON-FORMULARY MEDICATION REQUEST FORM
FAX (716) 887-8981 or TOLL FREE FAX 1-866-221-5784
TOLL FREE TELEPHONE 1-800-716-3230
The information contained in this facsimile may be
considered Protected Health Information.
The
BC/BS USE ONLY
Date: ______/_____/______
recipient of this information is obligated to protect
the confidentiality of this information and maintain it
in a safe and secure manner. Re-disclosure of the
information without the patient’s, or their authorized
Patient Name: ______________________________________________
representatives’
permission,
or
as
otherwise
permitted by law, is strictly prohibited. Unauthorized
use or disclosure of this information or failure to
maintain the confidentiality could subject you to Civil
ID#: ____________________________ DOB: ______/______/______
and/or Criminal penalties.
This information is
confidential and is only intended for the exclusive
use of the individual or entity named above. If the
reader of this message is not the intended recipient,
Diagnosis: _________________________________________________
you are hereby notified that any dissemination,
distribution or copying of this communication is
strictly prohibited. If you received this message in
Medication Requested: _______________________________________
error, please immediately notify the sender by
telephone to arrange for its return.
Dosage and Regimen Prescribed: _______________________________ Anticipated Duration*: ____________________
*
Maximum duration for approvals is one year, and may be less for acute care or at Plan discretion
Justification for Request (
Medications Tried
Where applicable, please list other medications, allergies or therapeutic
measures attempted and results; additional supporting documentation such as lab reports test results
should also be attached):
___________________________________________________________________________
________________________
___________________________________________________________________________
________________________
___________________________________________________________________________
________________________
___________________________________________________________________________
________________________
___________________________________________________________________________
________________________
Prescribing Physician Name (Please Print): ___________________________________________
Prescribing Physician Signature: ___________________________________________________
DEA # _______________________________
CB Provider #_______________________________
Telephone # (__________)_________________________
FAX # (___________)___________________________
BC/BS OF WNY USE ONLY
Pended
_____
(Information Needed to Complete Request (Our Decision Is Pending Your Response)):
DATE PENDED REQUEST WILL BE CLOSED: _____/_____/_____
Date: ____/_______/_____ Signature: ____________________________________________________
Determination: _____Denied
_____Approved Time Period: _________________________
Reason:
Date: ______/______/______ Signature: ____________________________________________________
Approvals are only valid if person has active prescription drug coverage through Blue Cross & Blue Shield of Western New York. This prior authorization is subject to all drug
therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify
our drug therapy guidelines for prospective services.
Revised 5-03
PRIOR APPROVAL/NON-FORMULARY MEDICATION REQUEST FORM
FAX (716) 887-8981 or TOLL FREE FAX 1-866-221-5784
TOLL FREE TELEPHONE 1-800-716-3230
The information contained in this facsimile may be
considered Protected Health Information.
The
BC/BS USE ONLY
Date: ______/_____/______
recipient of this information is obligated to protect
the confidentiality of this information and maintain it
in a safe and secure manner. Re-disclosure of the
information without the patient’s, or their authorized
Patient Name: ______________________________________________
representatives’
permission,
or
as
otherwise
permitted by law, is strictly prohibited. Unauthorized
use or disclosure of this information or failure to
maintain the confidentiality could subject you to Civil
ID#: ____________________________ DOB: ______/______/______
and/or Criminal penalties.
This information is
confidential and is only intended for the exclusive
use of the individual or entity named above. If the
reader of this message is not the intended recipient,
Diagnosis: _________________________________________________
you are hereby notified that any dissemination,
distribution or copying of this communication is
strictly prohibited. If you received this message in
Medication Requested: _______________________________________
error, please immediately notify the sender by
telephone to arrange for its return.
Dosage and Regimen Prescribed: _______________________________ Anticipated Duration*: ____________________
*
Maximum duration for approvals is one year, and may be less for acute care or at Plan discretion
Justification for Request (
Medications Tried
Where applicable, please list other medications, allergies or therapeutic
measures attempted and results; additional supporting documentation such as lab reports test results
should also be attached):
___________________________________________________________________________
________________________
___________________________________________________________________________
________________________
___________________________________________________________________________
________________________
___________________________________________________________________________
________________________
___________________________________________________________________________
________________________
Prescribing Physician Name (Please Print): ___________________________________________
Prescribing Physician Signature: ___________________________________________________
DEA # _______________________________
CB Provider #_______________________________
Telephone # (__________)_________________________
FAX # (___________)___________________________
BC/BS OF WNY USE ONLY
Pended
_____
(Information Needed to Complete Request (Our Decision Is Pending Your Response)):
DATE PENDED REQUEST WILL BE CLOSED: _____/_____/_____
Date: ____/_______/_____ Signature: ____________________________________________________
Determination: _____Denied
_____Approved Time Period: _________________________
Reason:
Date: ______/______/______ Signature: ____________________________________________________
Approvals are only valid if person has active prescription drug coverage through Blue Cross & Blue Shield of Western New York. This prior authorization is subject to all drug
therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify
our drug therapy guidelines for prospective services.
Revised 5-03