Get Prior Authorization And Formulary Exception Form

This guide provides clear, step-by-step instructions for users on how to fill out the Prior Authorization And Formulary Exception Form online. Completing this form accurately is essential for ensuring that necessary medications are authorized for coverage.

Follow the steps to complete the Prior Authorization And Formulary Exception Form

1. Press the ‘Get Form’ button to access the online form and open it for editing.
2. Begin by entering the patient's information in the designated fields, including their name, BCBSMA ID number, date of birth, and diagnosis or ICD-9-CM code. Indicate whether the patient is a BCBSMA employee by selecting 'Yes' or 'No,' and if 'Yes,' fax the request to (617) 246-4013.
3. Next, provide the physician's information. Fill in the physician's name, medical specialty, BCBSMA provider number/NPI number, telephone number, and fax number. Confirm if the fax number is secure for HIPAA compliance by circling 'Yes' or 'No.' If a different contact person is involved, please provide their name in the contact field.
4. Choose the appropriate section to complete based on the request's nature: Formulary Exception Request, Quality Care Dosing Override Request, or Outpatient Retail Pharmacy Prior Authorization Request. Each section includes specific fields that require your input.
5. For the Formulary Exception Request, list the non-covered drug you wish to prescribe, and select the reason for the request by checking the relevant boxes, providing details as necessary.
6. In the Quality Care Dosing Override Request section, specify the drug name, strength, quantity requested, and clinical reason for the override.
7. If selecting the Outpatient Retail Pharmacy Prior Authorization Request, enter the drug name, start and end dates (which must be one year or less), and any associated co-morbid diagnosis. For ®/®, provide the GFR and indicate whether the patient is certified with ESRD under Medicare.
8. Finally, ensure that the prescriber’s signature is included along with the date, and review the completed form for accuracy.
9. Once all sections are filled out correctly, save changes to the form. You can then download, print, or share the form as needed.

Complete the Prior Authorization And Formulary Exception Form online to streamline your medication authorization process.