Medicare Part B Drug Prior Authorization Request Form - Continuous Glucose Monitor (CGM) Form

Florida Blue Medicare is an independent licensee of the Blue Cross and Blue Shield Association. 115554 1223R Part B Continuous Glucose Monitor (CGM) Prior Authorization Request Form 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 that applying the 72-hour standard review timeframe might seriously jeopardize the life or health of the member or the member’s ability to regain maximum function. I. MEMBER INFORMATION II. PRESCRIBER INFORMATION Name: Name: ID Number: Specialty: Date of Birth: NPI: Address: Office Contact Name: Phone Number: Phone Number: Fax Number: III. CGM REQUESTED IV. CLINICAL INFORMATION CGM brand/model/NDC: Brand/model: Diagnosis (description, ICD-10 and Z codes): Is the member currently on insulin? ☐ Yes ☐ No Clinical rationale for CGM: Within six (6) months prior to ordering the CGM, has the treating practitioner had an in-person or Medicare-approved telehealth visit with the member to evaluate their diabetes control and determined that CGM criteria are met?
☐Yes ☐ No Date of last visit with treating practitioner: Note: Even if member is picking up their CGM at a pharmacy, this will be processed under Part B (medical/DME) benefit.
NDC: Requested CGM product(s): ☐CGM receiver (device) and supplies needed OR ☐CGM supplies only Is member currently using CGM? ☐Yes ☐ No How many units does the patient require PER MONTH? (If the request is for more than the standard monthly supply, please provide quantity requested and directions for use.) Start date of therapy: If CONTINUING therapy, include Florida Blue prior approval.
Prior Florida Blue approval Cert #: Note: Prescriber needs to submit a new prescription for the requested CGM to a local in-network or participating home delivery pharmacy, which will be supplied through the member’s PART B Benefit, if request is approved by Florida Blue. PRESCRIBER NAME SIGNATURE DATE & TIME VII. PERTINENT CLINICAL INFORMATION Clinical information is required to make a determination. Missing information and slow responses will delay completion of this request. PLEASE ATTACH pertinent medical history, progress notes, laboratory and diagnostic test results that may support approval. Additional notes can be included in the space below.