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Prescription drug medication request form - highmark west virginia

PRESCRIPTION DRUG MEDICATION REQUEST FORM FAX TO 1-866-240-8123
Fax each form separately. Please use a separate form for each drug.
Print, type or write legibly in blue or black ink. See reverse side for additional details PATIENT INFORMATION
Subscriber ID Number
CLINICAL / MEDICATION INFORMATION
Drug Name
Alternatives Tried / Used By Patient (if applicable)
Drug Name
Medical Rationale / Reason for Drug Therapy / Treatment Plan
PHYSICIAN INFORMATION (needed for mailing notification - please print legibly)
Physician Name
MEDICARE
COMMERCIAL
REQUEST TYPE
Once a clinical decision has been made, a decision letter will be mailed to the patient and physician.
To view the formulary on-line, please visit our web site at http://mydrugformularies.com.
INSTRUCTIONS FOR COMPLETING THE FORM
1. Submit a separate form for each medication.
2. Complete ALL information on the form.
NOTE: The prescribing physician (PCP or Specialist) should, in most cases, complete the form.
3. Please provide the physician address as it is required for physician notification.
4. Fax the completed form to 1-866-240-8123
Or mail the form to: Medical Management and Policy
P.O. Box 279; Pittsburgh, PA 15230
CLINICAL MANAGEMENT PROCEDURES
In general, when requesting coverage for a medication, the following information in the bullet points
below is required:
PRIOR AUTHORIZATION
Below is a list of common drugs and/or therapeutic categories that require prior authorization: Agents used for fibromyalgia (e.g. Cymbalta, Lyrica, Savella)
Testosterone therapies
Miscellaneous Items: contraceptives, Provigil, immediate release fentanyl products
Specialty drugs (e.g. Enbrel, Sutent, Tracleer, etc.)
MANAGED PRESCRIPTION DRUG COVERAGE (MRXC)
The MRXC program includes coverage for specific drug therapy categories with set thresholds or limits.
The MRXC program uses specific criteria as set forth by Pharmacy and Therapeutics Committee to assessthe information provided to support requests for additional quantities.
Below is a list of common drugs and/or therapeutic categories that are managed under our MRXCprogram: Medications used to treat Migraines (e.g. Amerge, Imitrex, Maxalt, etc.)
Medications used to treat Onychomycosis (Lamisil and Sporanox)
Leukotriene Modifiers (Singulair, Accolate, and Zyflo)
Pain Management (OxyContin, Opana ER, etc.)
Please note that the drugs and therapeutic categories managed under our Prior Authorization and MRXCprograms are subject to change based on the FDA approval of new drugs.
To view the formulary on-line, please visit our Web site at http://mydrug.formularies.com
Highmark Blue Cross Blue Shield West Virginia is an Independent Licensee of the Blue Cross and Blue Shield Association

Source: http://www.pfizerformularypro.com/restriction_documents/4980_Highmark%20BlueCross%20BlueShield%20WV%20(Open)%20Generic%20PA%20Form.pdf

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