Prior Authorization Form - Independence Blue Cross

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Today’s date: ___________________________________
Date medication needed: ____________________________
Prior Authorization Form
Direct Ship General Drug Request – Medical Benefit Drugs Only
IF YOU ARE ORDERING BOTULINUM TOXINS (BOTOX, DYSPORT, MYOBLOC, XEOMIN), PROLIA/XGEVA, STELARA,
SYNAGIS, XOLAIR, OR MAKENA/17 ALPHA-HYDROXYPROGESTERONE CAPROATE, PLEASE DOWNLOAD THE
APPROPRIATE DRUG-SPECIFIC FORM AT:
USE THIS FORM TO REQUEST ALL OTHER DRUGS AVAILABLE THROUGH THE DIRECT SHIP DRUG PROGRAM.
THE COMPLETE LIST OF ALL DRUGS AVAILABLE THROUGH THIS PROGRAM IS AVAILABLE AT:
REQUESTS FOR DRUGS THAT ARE NOT ON THE DIRECT SHIP DRUG LIST (SEE ABOVE) WILL NOT BE PROCESSED.
ONLY COMPLETED REQUESTS WILL BE REVIEWED.
Drug being requested:
Check one:
New start
Continued treatment
Patient information (please print)
Physician information (please print)
Patient name
Prescribing physician
Address
Office address
City, state, ZIP
City, state, ZIP
Patient telephone #
Office contact
Patient ID
Office telephone #
Date of Birth
Height
Fax #
Weight
NPI
No delivery requested; physician will use office supply. Authorization only.
Delivery requested to the physician’s office.
** A copy of the prescription must accompany the medication request for delivery.**
Physician specialty (specify all):
1)
Diagnosis for drug requested (must include ICD-10):
2)
Supporting member medical information/history
3)
Please add any member information that may be useful in the decision-making process.
Prescription Information:
4)
Quantity ________________________________
Refill x __________________________ month(s)
Instructions (include dose)
_____ every
day(s)/ week(s)/ month(s)
Physician’s Signature: ______________________________________________________________________
Please fax this completed form to 215-761-9580.
10/01/2015
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and
with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

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