Prior Approval/non-Formulary Medication Request Form - Blue Cross And Blue Shield Of Western New York - 2003

PRIOR APPROVAL/NON-FORMULARY MEDICATION REQUEST FORM

FAX (716) 887-8981 or TOLL FREE FAX 1-866-221-5784

TOLL FREE TELEPHONE 1-800-716-3230

The information contained in this facsimile may be

considered Protected Health Information.

The

BC/BS USE ONLY

Date: ______/_____/______

recipient of this information is obligated to protect

the confidentiality of this information and maintain it

in a safe and secure manner. Re-disclosure of the

information without the patient’s, or their authorized

Patient Name: ______________________________________________

representatives’

permission,

or

as

otherwise

permitted by law, is strictly prohibited. Unauthorized

use or disclosure of this information or failure to

maintain the confidentiality could subject you to Civil

ID#: ____________________________ DOB: ______/______/______

and/or Criminal penalties.

This information is

confidential and is only intended for the exclusive

use of the individual or entity named above. If the

reader of this message is not the intended recipient,

Diagnosis: _________________________________________________

you are hereby notified that any dissemination,

distribution or copying of this communication is

strictly prohibited. If you received this message in

Medication Requested: _______________________________________

error, please immediately notify the sender by

telephone to arrange for its return.

Dosage and Regimen Prescribed: _______________________________ Anticipated Duration*: ____________________

*

Maximum duration for approvals is one year, and may be less for acute care or at Plan discretion

Justification for Request (

Medications Tried

Where applicable, please list other medications, allergies or therapeutic

measures attempted and results; additional supporting documentation such as lab reports test results

should also be attached):

___________________________________________________________________________

________________________

___________________________________________________________________________

________________________

___________________________________________________________________________

________________________

___________________________________________________________________________

________________________

___________________________________________________________________________

________________________

Prescribing Physician Name (Please Print): ___________________________________________

Prescribing Physician Signature: ___________________________________________________

DEA # _______________________________

CB Provider #_______________________________

Telephone # (__________)_________________________

FAX # (___________)___________________________

BC/BS OF WNY USE ONLY

Pended

_____

(Information Needed to Complete Request (Our Decision Is Pending Your Response)):

DATE PENDED REQUEST WILL BE CLOSED: _____/_____/_____

Date: ____/_______/_____ Signature: ____________________________________________________

Determination: _____Denied

_____Approved Time Period: _________________________

Reason:

Date: ______/______/______ Signature: ____________________________________________________

Approvals are only valid if person has active prescription drug coverage through Blue Cross & Blue Shield of Western New York. This prior authorization is subject to all drug

therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify

our drug therapy guidelines for prospective services.

Revised 5-03