Hmo Part B Drug Prior Authorization Request Form

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Complete form in its entirety and fax to 1-877-528-5816,
PART B DRUG PRIOR AUTHORIZATION
attention PA pharmacist.
REQUEST FORM
Contact Blue Advantage Medical Management
Department at 1-866-508-7145 (option 5, option 3) if you
XOLAIR (OMALIZUMAB)
have questions.
Today’s date:
Request type:
Standard Review (14 days)
Expedited Review (72 hours) – By checking this box I certify that applying the 14 day standard
review timeframe might seriously jeopardize the life or health of the member or the member’s
ability to regain maximum function.
NOTE: Please complete all fields in the form. Missing information and lack of prompt response to requests for additional
information may delay response time. Please attach relevant supporting documentation such as labs, results of
diagnostic tests, and office visit notes to this request.
PATIENT INFORMATION
Patient name
DOB
Street address, city, state, zip
Plan Member ID#
Sex M
F
Weight
Drug
allergies
PRESCRIBER INFORMATION
Prescriber name
Office contact person
Street address, city, state, zip
Office phone
Office fax
DRUG DISPENSING AND ADMINISTRATION INFORMATION
Who is furnishing the drug?
Facility where drug is to be administered
Physician’s office or facility will furnish drug
Physician’s office
Member picking drug up at a pharmacy. IMPORTANT
Outpatient infusion center
NOTE: If member is picking drug up at pharmacy, this request
Center name: ____________________________
must be faxed to the Part D drug prior authorization
Home Infusion
department at 1-858-790-7100.
Agency name: ___________________________
Self-inject
MEDICATION
Xolair dose, route, frequency
New start
Continued treatment
Expected duration of therapy
Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.
15-071_H6453
18NW2246 11/15
Blue Advantage from HMO Louisiana, Inc. is an HMO plan with a Medicare contract. HMO Louisiana is a subsidiary of
Blue Cross and Blue Shield of Louisiana, independent licensees of the Blue Cross and Blue Shield Association.

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