Medicare Part B Drug Prior Authorization Request Form Form

Florida Blue Medicare is an independent licensee of the Blue Cross and Blue Shield Association. 114493 1223R Part B Drug Prior Authorization Request Form Certain requests for coverage require review with the prescribing physician. Please:
• Complete this form, and fax or call the number listed. • Note any information left blank or illegible may delay the review process. • Use one form per prior authorization request. Fax: 1-904-357-6699 Phone: 1-904-357-3900, Ext. 89277 REQUEST TYPE: ☐Standard Review (72 hours). ☐Expedited Review (24 hours). By checking this box, I certify application of the 72-hour standard review timeframe could seriously jeopardize the member’s health or life, or their ability to regain maximum function. I. MEMBER INFORMATION II. PRESCRIBER INFORMATION Name: Name: ID Number: Specialty: Date of Birth: NPI/DEA Number: Address: Facility Name & Address: Phone Number: Office Contact Name: Weight: Phone Number: Height: Fax Number: III. MEDICATION REQUESTED IV. DRUG DISPENSING AND ADMINISTRATION Drug Name: Where drug will be administered:
☐Physician’s office ☐Outpatient hospital: Name: _ ☐Inpatient hospital: Name: __ ☐Home ☐Other: ___ Directions/SIG
(dose, route, and frequency): Dose: Route: Frequency: If drug is administered in healthcare professional setting:
Will the provider be buying and billing, or will drug be procured from specialty pharmacy?
☐Buy and bill ☐Specialty pharmacy (only participating pharmacy is CVS/Caremark; otherwise obtain via Part D benefit) Note: If member is picking up drug at a pharmacy, must submit request for Part D coverage.
HCPCS/J-Code & modifier: Start date of therapy: If continuing therapy, include Florida Blue prior approval
Prior Florida Blue approval Cert #: V. ADDITIONAL CLINICAL INFORMATION ICD-10 Code: Diagnosis: Is the medication being requested for use in an ongoing investigational trial?  YES  NO VI. MEDICATION HISTORY (for this diagnosis) List therapeutic alternatives previously and currently used with start/end dates and outcomes: Drug Name, Strength, and Dosage Dates of Therapy (start/end dates) Reason for Discontinuation 1 2 3 Note: Step therapy is required, and the definition of medical necessity must be met, for certain higher-cost non-preferred medications: https://www.floridablue.com/providers/medical-pharmacy-info/part-b-step-therapy
PRESCRIBER NAME SIGNATURE DATE & TIME VII. PERTINENT CLINICAL INFORMATION Clinical information is required for a determination. Missing information and lack of prompt response to requests for additional information may delay response time. Please attach pertinent medical history, progress notes, laboratory, and diagnostic test results, which may support approval. Any additional notes can be included on the next page.

Florida Blue Medicare is an independent licensee of the Blue Cross and Blue Shield Association. 114493 1223R

Part B Drug Prior Authorization Request Form

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