Prior authorization

For members who have prescription drug coverage through Independence Blue Cross (Independence), prior authorization is required for certain prescribed formulary drugs in order for such drugs to be covered. The approval criteria were developed and endorsed by the Pharmacy and Therapeutics Committee and are based on information from the U.S. Food and Drug Administration, manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.

A request form must be completed for all medications that require prior authorization. Prior authorization requests are reviewed by our independent pharmacy benefits manager.

Submitting a prior authorization request

To simplify your experience with prior authorization and save time, please submit your prior authorization request to the pharmacy benefits manager through any of the following online portals:

• CoverMyMeds^®
• Surescripts^®

Prior authorization via fax

Submit prior authorization requests by fax using the forms listed below:
Commercial prior authorization forms

Select formulary

• General fax form
• Acute migraine agents
• CNS stimulants — high cumulative dose
• Immune modulating therapy
• Opioid management — Buprenorphine/naloxone (Bunavail^®/Suboxone^®/Zubsolv^®) and Buprenorphine (Subutex^®)
• Opioid Management — Morphine Milligram Equivalent (MME) > 90 mg/day, Long-acting opioids, Short-acting opioids for short term Use, and Quantity
• Opioid Management — Short-acting opioids for continuation beyond 30 days
• Cost-share exception policy for preventative medications and women’s preventive services
• Select formulary exception prior authorization request form

Premium formulary

• Dispense as written (DAW) override request form
• General fax form
• Health care reform copay waiver request form

Value formulary

• General fax form
• Acute migraine agents
• CNS stimulants — high cumulative dose
• Immune modulating therapy
• Opioid management — Buprenorphine/naloxone (Bunavail^®/Suboxone^®/Zubsolv^®) and Buprenorphine (Subutex^®)
• Opioid Management — Morphine Milligram Equivalent (MME) > 90 mg/day, Long-acting opioids, Short-acting opioids for short term Use, and Quantity
• Opioid Management — Short-acting opioids for continuation beyond 30 days
• Value formulary exception prior authorization request form

Medicare Part D coverage determination request forms

• 7 Days Supply Limit for Opioids Coverage Determination
• Androgens Coverage Determination
• Butalbital Combination Products Coverage Determination
• Duplicative Long-Acting Opioid Therapy Coverage Determination
• Duragesic^® (fentanyl) Transdermal Patch Coverage Determination
• Estrogens Coverage Determination
• General Coverage Determination
• Hepatitis C Agents Coverage Determination
• Hetlioz^® and Hetlioz LQ™ Coverage Determination
• Hospice Information for Medicare Part D Plans
• H.P. Acthar^® Coverage Determination
• Humira^® Coverage Determination
• Intradialytic Parenteral Nutrition (IDPN)/Intraperitoneal Nutrition (IPN)/Total Parenteral Nutrition (TPN) Prior Authorization
• Kadian^® (morphine sulfate extended-release [ER]), MorphaBond™ ER, and MS Contin^® (morphine sulfate ER) Coverage Determination
• Lidoderm^® (lidocaine patch) and ZTlido™ Coverage Determination
• Medicare Administrative Coverage Determination for Part B versus D coverage
• Morphine Equivalent Dose Coverage Determination
• Non-Benzodiazepine Hypnotics Coverage Determination
• Opioid-acetaminophen (APAP) Combination Therapy
• Opioid-Benzodiazepine Combination Therapy
• Opioid-Medication Assisted Treatment (MAT) Combination Therapy
• Opioid-Prenatal Vitamin Combination Therapy
• Oral Chemotherapy Agents
• Oxycodone extended-release (ER) & OxyContin^®
• Praluent^®
• Prolia^®
• Proton Pump Inhibitors (PPIs)
• Repatha^®
• Rhopressa^®
• Roxicodone^® (oxycodone immediate-release)
• Skeletal Muscle Relaxants
• Tier Exception

Request form instructions

Providers

• When completing a prior authorization form, be sure to supply all requested information.
• Fax completed forms to 1-888-671-5285 for review. Make sure you include your office telephone and fax numbers.
• You will be notified by fax if the request is approved. If the request is denied, you and your patient will receive a denial letter.
• If you have not received a response after two business days from when you submitted your completed form, please call our pharmacy benefits manager at 1-888-678-7012.

Members

• Take the appropriate request form to your physician for completion.
• You or your physician should fax the completed form to 1-888-671-5285 for review.
• If you have not received a response after two business days from when your completed form was submitted, please contact the physician who requested your prior authorization.

As with all our preapproval requirements, the prior authorization form must be completed in full to avoid delay. If you have questions about the preapproval process, call 1-800-ASK-BLUE.

Please refer to the drug formularies page for more information about the different formularies offered by Independence.