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
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