Process for Requesting Drug Coverage from a Pharmaceutical Management Program

Pharmaceutical management procedures encompass programs such as prior authorization, managed prescription drug coverage (MCxC), and Formulary Management. Physicians may request coverage for a product from any of these programs.
Physicians may submit requests for drug coverage if all of the following criteria are met:

  1. The request must provide evidence of the ineffectiveness of formulary or preferred alternatives or reasonable expectation of harm.
  2. The drug must be covered under member's benefit plan (i.e. member must have coverage for oral contraceptives if physician is requesting coverage for a nonformulary oral contraceptive).
  3. The member would otherwise be 100% responsible for the cost of the drug.

All requests will be considered standard unless the requesting physician indicates the need for an expedited review. For standard requests, a decision will be communicated within two business days after receipt of all supporting information reasonably necessary to complete the review. For expedited requests, a decision will be rendered as expeditiously as the member's health requires, but no later than one business day (not to exceed 72 hours). Expedited requests will be limited to those instances where:

  • The physician filing the request states that an expedited review is necessary based on the member's medical condition such that the time frame required for the standard request process would compromise the member's life, health, or functional status.
  • The member is discharged from an acute care environment with a prescription for a nonformulary drug that the requesting physician determines is necessary to complete a specific course of therapy.
  • The physician wishes to prescribe a medication that requires administration in a time frame that will not be met if the standard request process is used.

If you need a copy of the medication request form, print it from your computer, and complete it in accordance with the directions below.

Instructions for Completing the Request for Drug Coverage Form

Please note that this form is only applicable for those members who have a closed formulary benefit design or prior authorization. Requests are for individual patients only.

  1. Complete all information requested. The prescribing physician (Primary Care Physician or Specialist) should, in most cases, complete the form.
  2. Submit a separate form for each drug you wish to have reviewed.
  3. Keep a copy for your records.
  4. Mail the form to:

        Highmark Blue Shield
        Prescription Drug Program
        P.O. Box 279
        Pittsburgh, PA 15230
               OR
        Fax the form to: 412-544-7546
               OR
        For expedited requests, phone 1-800-656-2485 to leave a message on the dedicated voice mail answering system.

Note: Your message should include all necessary information found on the request form. We suggest using the request form as a template when you call in order to avoid unnecessary delays in processing your request. Please note that the use of the voice mail system is reserved for expedited requests only.
When an exception request is approved, both the physician and the member will be notified of the approval. When an exception request is denied, both the physician and the member will be notified of the denial. The member's denial letter explains the right to file a grievance or appeal if he or she considers the decision unacceptable.


Appeals and Grievances

A member who is not satisfied with the outcome of a decision may file a grievance through the Initial Grievance Committee. Information on the initial grievance process appears in the member's handbook.

Last updated on 10/3/2017

 

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