Drug Prior Authorization Request Form Form

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 490066.0426 Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer. CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible for its products and services. BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions regarding the products or services they offer, you
should contact the vendor(s) directly. New Mexico Uniform Prior Authorization Form
Submission Information For the following members of
Blue Cross and Blue Shield of New Mexico: Submit the prior authorization form: Coverage review: Commercial members for physical health services Electronically: Availity® Essentials Fax:
866-589-8253 M-F: 8 a.m. – 5 p.m. MT
Phone: 800-325-8334 After-hours coverage review
888-898-0070 Commercial members for
behavioral health services Electronically: Availity Fax:
877-361-7659 or

312-946-3737 24-hour coverage review
Phone: 888-898-0070 Commercial members for
pharmacy services Electronically: CoverMyMeds Fax:
877-243-6930 24-hour coverage review
Phone: 800-544-1378 Medicaid members
for physical health services Electronically: Availity Fax:
505-816-3854 M-F: 8 a.m. – 5 p.m. MT
Phone: 877-232-5518 After-hours coverage review
Phone: 877-232-5518 Medicaid members
for behavioral health services Electronically: Availity Fax:
888-530-9809 M-F: 8 a.m. – 5 p.m. MT
Phone: 877-232-5518 After-hours coverage review
Phone: 877-232-5518 Medicaid members
for pharmacy services Electronically: CoverMyMeds Fax:
877-243-6930 24-hour coverage review Phone: 866-689-1523 PO Box 660058 Dallas, TX 75266-0058 www.bcbsnm.com Phone: 800-835-8699 Fax: 800-773-1521

New Mexico Uniform Prior Authorization Form To file electronically, send to: See Cover Sheet To file via facsimile, send to:
See Cover Sheet

1. Priority and Frequency Standard  Services scheduled for
   this date: Urgent/Expedited  Provider certifies that applying the standard review timeline may seriously jeopardize the life or health of the enrollee. Frequency Initial  Extension  Previous Authorization #:
2. Enrollee Information Enrollee name: Enrollee date of birth: Subscriber/Member ID #: Enrollee street address: City: State: Zip code:
3. Provider Information: Ordering Provider  Rendering Provider  Both  Please note: processing delays may occur if rendering provider does not have appropriate documentation of medical necessity. Ordering provider may need to initiate prior authorization. Provider name: Provider type/specialty: Administrative contact: NPI #: DEA # if applicable: Clinic/facility name: Clinic/pharmacy/facility street address: City, State, Zip code: Phone number and ext.: Facsimile/Email:
4. Requested medical or behavioral health course of treatment/procedure/device information (skip to Section 8 if drug requested) Service description: Setting/CMS POS Code
   Outpatient  Inpatient  Home  Office  Other  Please specify if other:
5. HCPCS/CPT/CDT/ICD-10 CODES Latest ICD-10 Code HCPCS/CPT/CDT Code Medical Reason
6. Frequency/Quantity/Repetition Request Does this service involve multiple treatments?
   Yes  No 
   If “No,” skip to Section 7. Type of service: Name of therapy/agency: Units/Volume/Visits requested: Frequency/length of time needed:
7. Prescription Drug Diagnosis name and code: Patient Height (if required): Patient Weight (if required): Route of administration Oral/SL  Topical  Injection  IV  Other  Explain if “Other:” Administered: Doctor’s office  Dialysis Center  Home Health/Hospice  By patient 

BCBSNM Commercial/Retail plans Medication Requested Strength (include both loading and maintenance dosage) Dosing Schedule
(including length of therapy) Quantity per month
or Quantity Limits Is the patient currently treated with the requested medication(s)? Yes  No  If “Yes,” when was the treatment with the requested medication started? Date:
Anticipated medication start date (MM/DD/YY): General prior authorization request. Explain the clinical reason(s) for the requested medications, including an explanation for selecting these medications over alternatives: Rationale for drug formulary or step-therapy exception request:  Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure, Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s).  Patient is stable on current drug(s), high risk of significant adverse clinical outcome with medication change. Specify anticipated significant adverse clinical outcome below.  Medical need for different dosage and/or higher dosage, Specify below: (1) Dosage(s) tried; (2) explain medical reason.  Request for formulary exception, Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome  Other (explain below) Required explanation(s): List any other medications patient will use in combination with requested medication: List any known drug allergies:

8. Previous services/therapy (including drug, dose, duration, and reason for discontinuing each previous service/therapy) Date Discontinued: Date Discontinued: Date Discontinued: Attestation I hereby certify and attest that all information provided as part of this prior authorization request is true and accurate. Requester Signature
   Date
   DO NOT WRITE BELOW THIS LINE. FIELDS TO BE COMPLETED BY PLAN. Authorization #
   Contact name
   Contact’s credentials/designation SIGN