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It provides fields to capture member identifiers, diagnosis details including ICD-10 codes, drug information such as HCPCS J-code, requested name, strength/dose, directions, quantity, and start date. The form collects medical rationale and treatment plan, site of care and supplier information, ordering/attending provider details, and ordering provider signature with required identifiers. 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Requests may alternatively be submitted by phone using the provided option selections.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What member details are required on the form?",{"text":113,"@type":109},"The form requests the member ID number, member name, member date of birth, member phone number, and member address including city, state, and zip code.",{"name":115,"@type":106,"acceptedAnswer":116},"What drug and clinical information must be included?",{"text":117,"@type":109},"Include diagnosis code and description (ICD-10), HCPCS J-code, requested drug name, drug strength or dose, quantity, directions, requested start date of service, and a medical rationale/treatment plan with supporting clinical information.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288211,1789633242,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},13056703019404,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Medical Specialty Drug Authorization Request Form  \nPlease print, type or write legibly in blue or black ink. Once completed, please fax this form to the designated fax number for medical injectables at 833-581-1861. Authorization requests may alternatively be submitted via phone by calling 1-800-452-8507 (option 3, option 2) .  \n*Please note this form does NOT represent a legal prescription order, and the official prescription order/referral must be sent to the servicing pharmacy provider.  \n\n| MEMBER INFORMATION |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Member ID Number |  |  |  |  | Group Number (If Available) |  |  |  |  |  |\n| Member Name |  |  |  |  | Member DOB |  | Member Phone Number |  |  |  |\n| Member Address City State Zip Code |  |  |  |  |  |  |  |  |  |  |\n| DRUG INFORMATION |  |  |  |  |  |  |  |  |  |  |\n| Diagnosis Code (ICD-10) | Diagnosis Code Description |  |  |  |  |  |  |  |  |  |\n| HCPCS Code (J-Code) | Requested Drug Name |  |  |  |  | Drug Strength or Dose |  | Quantity (\\# of doses/visits) |  |  |\n| Directions |  |  |  |  |  | Requested Start Date of Service |  |  |  |  |\n| MEDICAL RATIONALE / REASON FOR DRUG THERAPY / TREATMENT PLAN (please include supporting clinical information in your request) |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |\n| SITE OF CARE |  |  |  |  |  |  |  |  |  |  |\n| Place of Service (please select one)\u003Cbr>☐ Home Infusion (12) ☐ Office – Professional (11) ☐ Ambulatory Infusion Suite – Professional (49) ☐ Outpatient Hospital (22) Is the site of care affiliated with a hospital or will the claim be billed as a facility claim? ☐ Yes ☐ No |  |  |  |  |  |  |  |  |  |  |\n| Place of Service Name |  |  | NPI |  | Tax ID |  | Phone Ext. |  |  | Fax |\n| Place of Service Address City State Zip Code |  |  |  |  |  |  |  |  |  |  |\n| Drug Supplier Information (please select one)\u003Cbr>☐ Supplied by a Specialty Pharmacy (for Home Infusion, Office – Professional, or Ambulatory Infusion Suite – Professional)\u003Cbr>Name of Specialty Pharmacy:   NPI:  \u003Cbr>☐ Buy & Bill (for Office – Professional or Outpatient Hospital administration)\u003Cbr>Ship To (please select one)\u003Cbr>☐ Physician’s Office ☐ Member’s Home ☐ Other   |  |  |  |  |  |  |  |  |  |  |\n| ORDERING/ATTENDING PROVIDER INFORMATION (Required for mailing notification – Please print legibly) |  |  |  |  |  |  |  |  |  |  |\n| Physician Name |  |  | NPI |  |  | Phone Ext. |  |  |  | Fax |\n| Physician Address City State Zip Code |  |  |  |  |  |  |  |  |  |  |\n| Physician Signature (REQUIRED) |  |  |  |  |  | DEA (if applicable) |  |  | Date |  |\n| Contact Name |  |  |  | Contact Phone Ext. |  |  |  |  |  |  |\n| REQUEST TYPE |  |  |  |  |  |  |  |  |  |  |\n| Initial Request\u003Cbr>☐ Expedited Request ☐ Standard Request |  | Appeal\u003Cbr>☐ Peer to Peer ☐ Expedited Appeal ☐ Standard Appeal |  |  |  |  |  |  |  |  |\n\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: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield. All references to“Highmark” in this document are references to the H","cbCain0sBU3kK08b","https://ap.wps.com/l/cbCain0sBU3kK08b","pdf",186325,"English","# Member information\n# Drug information\n# Medical rationale / treatment plan\n# Site of care\n# Drug supplier information\n# Ordering/attending provider information\n# Request type","[{\"question\":\"How should the Medical Specialty Drug Authorization Request Form be completed and submitted?\",\"answer\":\"Complete it by printing, typing, or writing legibly in blue or black ink, then fax it to the designated fax number. Requests may alternatively be submitted by phone using the provided option selections.\"},{\"question\":\"What member details are required on the form?\",\"answer\":\"The form requests the member ID number, member name, member date of birth, member phone number, and member address including city, state, and zip code.\"},{\"question\":\"What drug and clinical information must be included?\",\"answer\":\"Include diagnosis code and description (ICD-10), HCPCS J-code, requested drug name, drug strength or dose, quantity, directions, requested start date of service, and a medical rationale/treatment plan with supporting clinical information.\"}]","Medical Specialty Drug Authorization Request Form | PDF"]