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Collects member subscriber identifiers and demographics, prescribing physician details (including NPI), and medication specifics such as drug name, strength, requested quantity and day supply, directions, and diagnosis/ICD-10 codes. Includes clinical questions on induction dosing, current therapy status, disease stability or improvement, specialty prescribing/consultation, prior therapeutic failures, member weight, and additional request information, plus provider certification that information is true and medically necessary. Submission via fax or mail.","Medication Prior Authorization Form  \nFax to 1-866-240-8123  \nChronic Inflammatory Diseases  \nMember Information:  \n\n| Subscriber’s ID Number |  | Subscriber’s Group Number |\n| --- | --- | --- |\n| Member’s Name | Phone | Date of Birth |\n| Address City State Zip Code |  |  |\n\nProvider Information:  \n\n| Physician’s Name |  | NPI | Phone | Fax |\n| --- | --- | --- | --- | --- |\n| Address City State Zip Code |  |  |  |  |\n| Suite / Building | Physician’s Signature |  |  | Date |\n\nMedication Information:  \n\n| Drug Name | Drug Strength | Requested Quantity | Requested Day Supply ☐ 30 days\u003Cbr>☐ 90 days\u003Cbr>☐ Other:   |\n| --- | --- | --- | --- |\n| Directions |  |  |  |\n| Diagnosis and/or ICD-10 code(s) |  |  |  |\n| 1. Does the member require induction dosing? |  | Yes | No |\n| 2. Is the member currently on therapy with the requested medication? |  | Yes | No |\n| If YES: |  |  |  |\n| 2a. Is there clinical documentation of disease stability or improvement while on this medication? |  | Yes | No |\n|  |  |  |  |\n\nClinical Information:  \n1. The requested medication is being prescribed by, or in consultation, with a:  \n􀂇 Rheumatologist 􀂇 Dermatologist  \n􀂇 Ophthalmologist 􀂇 Geneticist  \n􀂇 Gastroenterologist 􀂇 Allergist  \n􀂇 Immunologist 􀂇 Pulmonologist  \n􀂇 Physician specializing in the treatment of autoinflammatory disorders  \n􀂇 Other:    \n2. Has the member experienced therapeutic failure to any of the following therapies?  \nPlease select ALL that apply:  \n􀂇 Methotrexate 􀂇 Leflunomide 􀂇 Sulfasalazine  \n􀂇 Cyclosporine 􀂇 Hydroxychloroquine 􀂇 Phototherapy (e.g., PUVA, UVB)  \n􀂇 Azathioprine 􀂇 An NSAID (e.g., ibuprofen) 􀂇 A local glucocorticoid injection  \n􀂇 Mercaptopurine 􀂇 A systemic corticosteroid (e.g.,  \nprednisone)  \n􀂇 Other(s):  \n___________________________________________________________________________  \n___________________________________________________________________________  \n3. Please provide the member’s weight and include the unit of measure (for example, lb or kg):  \n4. Please provide any additional information pertinent to this request:  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \n_________________________________________________________________________________________  \nThe submitting provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the member. Note: Payment is subject to member eligibility. Authorization does not guarantee payment.  \nINSTRUCTIONS FOR COMPLETING THIS FORM  \n1. Submit a separate form for each medication.  \n2. Please print, type or write legibly in blue or black ink.  \n3. Complete ALL information on the form.  \nNOTE: The prescribing physician (PCP or Specialist) should, in most cases, complete the form.  \n4. Please provide the physician address as it is required for physician notification.  \n5. Fax the completed form and all clinical documentation to 1-866-240-8123 Or mail the form to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222  \nThe following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc. , Highmark Benefits Group Inc. , First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc. , Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highm","cbCaikhTB8fMsh60","https://ap.wps.com/l/cbCaikhTB8fMsh60","pdf",273861,3,"English","en",105,"# Member Information\n## Provider Information\n## Medication Information\n## Clinical Information\n## Submission Instructions","[{\"question\":\"What member information is required on this prior authorization form?\",\"answer\":\"The form requests the subscriber’s ID number and group number, member name, phone, date of birth, and address (city/state/zip).\"},{\"question\":\"What medication details must be completed?\",\"answer\":\"Required fields include drug name and strength, requested quantity, requested day supply (30 or 90 days or other), directions, and diagnosis and/or ICD-10 code(s).\"},{\"question\":\"How does the form require documenting treatment history and clinical justification?\",\"answer\":\"It asks whether induction dosing is needed, whether the member is currently on the requested medication, and if there is documentation of disease stability or improvement. It also collects whether prior therapeutic failure occurred to listed therapies and whether the prescribing is with a relevant specialist, plus member weight and any additional pertinent information.\"}]","Chronic Inflammatory Diseases - Medication Prior Authorization Form | PDF",1789633231,{"code":4,"msg":75,"data":76},"ok",{"site_id":69,"language":68,"slug":77,"title":59,"keywords":78,"description":60,"schema_data":79,"social_meta":134,"head_meta":136,"extra_data":138,"updated_unix":139},"chronic-inflammatory-diseases-medication-prior-authorization-form","",{"@graph":80,"@context":133},[81,96,116],{"@type":82,"itemListElement":83},"BreadcrumbList",[84,88,91,93],{"item":85,"name":86,"@type":87,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":89,"name":10,"@type":87,"position":90},"https://docshare.wps.com/template/",2,{"item":92,"name":36,"@type":87,"position":66},"https://docshare.wps.com/template/forms/",{"item":94,"name":59,"@type":87,"position":95},"https://docshare.wps.com/template/chronic-inflammatory-diseases-medication-prior-authorization-form/288201/",4,{"url":94,"name":59,"@type":97,"image":98,"author":103,"headline":59,"publisher":105,"fileFormat":108,"inLanguage":68,"description":60,"dateModified":109,"datePublished":110,"encodingFormat":108,"isAccessibleForFree":111,"interactionStatistic":112},"DigitalDocument",{"url":99,"@type":100,"width":101,"height":102},"https://docshare.wps.com/thumbnails/chronic-inflammatory-diseases-medication-prior-authorization-form/288201.png","ImageObject",442,249,{"name":57,"@type":104},"Person",{"url":85,"name":106,"@type":107},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":113,"interactionType":114,"userInteractionCount":90},"InteractionCounter",{"@type":115},"ViewAction",{"@type":117,"mainEntity":118},"FAQPage",[119,125,129],{"name":120,"@type":121,"acceptedAnswer":122},"What member information is required on this prior authorization form?","Question",{"text":123,"@type":124},"The form requests the subscriber’s ID number and group number, member name, phone, date of birth, and address (city/state/zip).","Answer",{"name":126,"@type":121,"acceptedAnswer":127},"What medication details must be completed?",{"text":128,"@type":124},"Required fields include drug name and strength, requested quantity, requested day supply (30 or 90 days or other), directions, and diagnosis and/or ICD-10 code(s).",{"name":130,"@type":121,"acceptedAnswer":131},"How does the form require documenting treatment history and clinical justification?",{"text":132,"@type":124},"It asks whether induction dosing is needed, whether the member is currently on the requested medication, and if there is documentation of disease stability or improvement. It also collects whether prior therapeutic failure occurred to listed therapies and whether the prescribing is with a relevant specialist, plus member weight and any additional pertinent information.","https://schema.org",{"og:url":94,"og:type":135,"og:title":59,"og:site_name":106,"og:description":60},"article",{"robots":137,"canonical":94},"index,follow",{"doc_id":55,"site_id":69},1790207352]