Get Quantity Limit Override Request Form - Blue Cross Blue Shield Of ... - Bcbstx

Completing the Quantity Limit Override Request Form is essential for users seeking exceptions for prescribed medications from Blue Cross Blue Shield of Texas. This guide provides step-by-step instructions to assist users in filling out the form accurately and efficiently.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in the date of request at the top of the form. This helps to document when the request is initiated.
3. In the 'BCBSTX Member Information' section, enter the patient's first and last name, address, city, state, ZIP code, BCBSTX ID number, and date of birth accurately.
4. Proceed to the 'Prescribing Physician / Provider Information' section. Fill in the provider's first and last name, medical license or DEA number, telephone number, fax number, and address.
5. Ensure the prescribing physician's signature is included, which validates the request.
6. Next, fill out the 'Requested Medication Information' section by providing the drug name, drug strength, quantity requested per month, and therapy duration. Important: input the route of administration.
7. Document the ICD-9 code along with previous drug therapies that have been tried and their outcomes.
8. For a complete application, attach a detailed letter of medical necessity and a copy of the patient’s medical records related to the diagnosis and therapies attempted.
9. Review all sections for completeness before finalizing.
10. Once completed, save your changes, and you have the option to download, print, or share the form.

Complete your Quantity Limit Override Request Form online today for prompt processing.