Form 04hq1094 - Drug Authorization Form - Bcbs Of Louisiana
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1CONFIDENTIAL
PATIENT INFORMATION
DRUG AUTHORIZATION FORM
®
®
An independent licensee of the Blue Cross and Blue Shield Association.
P.O. Box 98031
Baton Rouge, Louisiana
70898-9031
●
●
Phone: 800-842-2015 Fax: 877-837-5922
PATIENT DATA
Last Name
First Name
Policy Number
Date of Birth
Age
REQUESTING
Last Name
First Name
Contact Name
Fax Number
PHYSICIAN DATA
(
)
BCBSLA Provider Number
Area of Practice/Specialty Name of Place of Treatment Treatment Ctr Provider # Phone Number
(
)
Provider Address
Diagnosis Code(s) (ICD-10):
CPT-4/HCPCS Code
Other Codes
1)
2)
REQUESTED DRUG INFORMATION
Indication/Diagnosis
Drug Name
Strength/Dose/Directions
Anticipated Start Date and
Length of Therapy
THIS REQUEST REPRESENTS:
Re-authorization/Continuation of Therapy
Initial Therapy
PERTINENT LAB INFORMATION
CrCL:___________ ml/min
Hemoglobin:_____________ g/dL
Test Date:______________
T-Score:______________
Hematocrit:________________ %
Test Date:______________
Triglyceride:______mg/dL
Transferrin Saturation:________%
Test Date:______________
Other:________________
Ferritin:________________ ng/mL
Test Date:______________
Other:_______________________
Pre-treatment Serum IgE level:_____________ IU/ML
FEV1/PEF Predicted Value:__________%
Test Date:_______________
PEF Variability:_________%
Patient weight:___________ kg
Date wt obtained:__________
Other:_________________
Other:____________________
CLINICAL INFORMATION
Prior Medications (Name, strength, and frequency)
Adverse
Treatment
Date Started
Length of Therapy
(Attach additional pages if needed)
Reaction
Failure
If applicable, is there clinical evidence or patient history that suggests a step 1 medication will be ineffective or cause an adverse
reaction to the patient?
Yes
No
If so, please explain:__________________________________________________________________________________________
List any other relevant clinical info if applicable:______________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Yes
No Will the patient be receiving the drug in the physician’s office? If no, list name of servicing provider/facility:
_____________________________________________________________________________________________________________
PHYSICIAN SIGNATURE
DATE
__________________________________________________
_______________________________________
Prescribing Physician
Note: On behalf of Blue Cross and Blue Shield of Louisiana, prior authorizations are administered by Express Scripts, Inc., an
independent pharmacy benefit management company. Please note that the authorization is not a guarantee of payment. Payment is
subject to the member’s eligibility, benefits, and pre-existing condition limitations at the time the services are provided. We recommend
you contact BCBSLA at 800-922-8866 to verify benefits. The submitting provider certifies that the information contained herein is
true, accurate, and complete and the requested services are medically necessary to the health of the patient.
04HQ1094 R12/12
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company
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