Mm-060 (r7-07)

http://highmark.formularies.com
http://highmark.medicare-approvedformularies.com
Specialty Drug Request Form
Once completed, please fax this form to 1-866-240-8123.
To view our formularies on-line, please visit our Web site at the addresses listed above. Please use a separate form for each drug.
Print, type or WRITE LEGIBLY and complete form in full. If approved, Highmark will forward to Medmark, Inc. Medmark can be reached at 888-347-3416. Note: If you do not want this prescription to be sent to Medmark, check here ■.
PRESCRIPTION INFORMATION
*** (When completed, this section represents a legal prescription) ***
Subscriber ID Number
Group Number
Patient Name
Phone Number
Date of Birth
Patient Address
Drug name
Strength
Quantity
(only specialty drugs)
Directions
Diagnosis
Date Rx needed
Ship to (please check one)
■ Physician’s Office
■ Patient’s Home
■ Other
Physician Signature
(required)
Alternatives Tried / Used by Patient (if applicable)
Drug Name
Strength
Documentation of Failure of Therapy
Drug Name
Strength
Documentation of Failure of Therapy
Medical Rationale / Reason for Drug Therapy / Treatment Plan
PHYSICIAN INFORMATION (needed for mailing notification – please print legibly)
Physician Name
Physician Address
FOR INTERNAL REVIEW
■ Approved
■ Denied
■ Not Applicable
■ Benefit Denial
Notification of Decision Given: ■
Internal Rep:
Reason Code
Decision Date
Reviewer’s Initials
Contact Name:
Once a clinical decision has been made, a decision letter will be mailed to the patient and physician.
For other helpful information, please visit the Highmark Web site at: www.highmark.com
Highmark Blue Shield, Highmark Senior Resources and Highmark Health Insurance Company are Independent Licensees of the Blue Cross and Blue Shield Association. Medmark is an independent specialty pharmacy company that does not Provide Highmark Blue Shield products or services. Medmark is solely responsible for the specialty pharmacy products it provides. Instructions for Completing the Specialty Drug Request Form
1. Submit a separate form for each medication.
2. Complete ALL information on the form.
NOTE: The prescribing physician (PCP or Specialist) should, in most cases, complete the form.
3. Please provide the physician address as it is required for physician notification.
4. Fax the COMPLETED form to 1-866-240-8123
Medical & Pharmacy Affairs
P.O. Box 279
Pittsburgh, PA 15230
Clinical Management Procedures
In general, when requesting coverage for a medication, the following information identifiedbelow is required: Non-Formulary
• Most products: documentation of a trial of at least two formulary products.
Specialty Drugs Requiring Prior Authorization
For the following specialty drugs and/or therapeutic categories, the diagnosis, applicable labdata, and involvement of specialists are required, plus additional information as specified: Therapeutic Category
Required Information
Anti-rheumatic medications
Osteoporotic medications
At least two other osteoporotic therapies Growth hormones
Interferons
(Actimmune, Avonex, Betaseron, Infergen,Intron A, PEG-Intron, Pegasys, Rebif,Roferon-A) Miscellaneous
(Fertility agents, Gleevec, Raptiva, Nexavar,Revlimid, Thalomid, Revatio, Sprycel, Sutent,Tarceva, Tykerb, Zolinza) Important Note: Please use the standard “Prescription Drug Medication Request Form” for all
non-specialty drugs that require prior authorization.
For other helpful information, please visit the Highmark Web site at: www.highmark.com

Source: http://lbt.iu12.org/images/LBTforms%5CHideDirectoryName%5CHighmark%5CHighmark%20Blue%20Shield%20Specialty%20Drug%20Request%20Form.pdf