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Note that not filling in required fields (Marked with an *) will cause your submission to be rejected.

Select your browser type and follow these instructions to activate and enable JavaScript or contact your administrator if you continue to experience issues.

Internet Explorer

Follow these instructions to activate and enable JavaScript in Internet Explorer.

PC

Click the gear icon/Tools menu to the right of the Internet Explorer address bar.
Select Internet Options from the drop-down menu.
Next, select the Security tab at the top of the dialog box.
Then, select the earth (Internet) icon.
Then select the Custom Level button under the Security level for this zone section.
Locate the Scripting section within the list.
Under Active Scripting, select Enable, then hit OK.
Answer yes to the following conformation box.
Hit OK to close the Internet Options window.
Finally, refresh your browser.

Firefox

Follow these instructions to activate and enable JavaScript in Firefox.

PC & MAC

Open a new Firefox browser window or tab.
Copy the following then paste it into the Firefox address bar:about:config
Hit the Enter key.
On the following page, click the button: "I'll be careful, I promise!"
Find the javascript.enabled row under the Preference Name heading.
Double-click anywhere within the javascript.enabmed row to toggle the value from "False" to "True".
Finally, refresh your browser.

Safari

Follow these instructions to activate and enable JavaScript in Safari.

PC

In the Edit drop-down menu at the top of the window, select Preferences...
Select the Security icon/tab at the top on the window.
Then, click the Enable JavaScript checkbox.
Close the dialog box to save your changes.
Finally, refresh your browser.

MAC

Select Safari from the Apple/System bar at the top of the screen.
From the drop-down menu, select Preferences.
Select the Security icon/tabg at the top of the window.
Check the Enable JavaScript checkbox under the Web content category.
Close the dialog box to save your changes.
Finally, refresh your browser.

Opera

Follow these instructions to activate and enable JavaScript in Opera.

PC

In the Tools drop-down menu at the top of the window, select Preferences...
Select the Advanced tab at the top on the Preferences window.
Find the Content item in the list on the left-side of the window and select it.
Then, click the Enable JavaScript checkbox.
Click Ok to save your changes and close the Preferences window.
Finally, refresh your browser.

MAC

Select Opera from the Apple/System bar at the top of the screen.
From the drop-down menu, select Preferences.
Select the Security icon/tabg at the top of the window.
Check the Enable JavaScript checkbox under the Web content category.
Close the dialog box to save your changes.
Finally, refresh your browser.

Chrome

Follow these instructions to activate and enable JavaScript in Chrome.

PC

To the right of the address bar, click the icon with 3 stacked horizontal lines.
From the drop-down menu, select Settings
At the bottom of the page, click the Show advanced settings... link.
Under the Privacy section, click the Content settings... button.
Under the JavaScript heading, select the Allow all sites to run JavaScript radio button.
Finally, refresh your browser.

MAC

Select Chrome from the Apple/System bar at the top of the screen.
Select Preferences... from the drop-down menu.
In the left-hand column, select Settings from the list.
At the bottom of the page, click the Show advanced settings... link.
Under the Privacy section, click the Show advanced settings... button.
Under the JavaScript heading, select Allow all sites to run JavaScript radio button.
Finally, refresh your browser.

iOS

Follow these instructions to activate and enable JavaScript in iOS on the iPhone and iPad.

Select the Settings application/icon on the iPhone home screen.
Select Safari on the following screen.
Select Advanced, located near the bottom of the following screen.
Move the JavaScript toggle to the right so that it highlights green.

Andriod

Follow these instructions to activate and enable JavaScript on your Android.

Select Browser or Internet to open the web browser.
Select Menu
Select More then Settings.
Finally select Enable JavaScript

Prior Authorization Gocovri

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Required *
Enter Patient Information
Drug Name: *
Blue KC ID (Not SS#): *
- i
- i
- i
Patient First Name: *
Patient Middle Initial:
Patient Last Name: *
Date of Birth: *
Patient Group ID: *
ICD-10 Diagnosis Codes: *
Diagnosis Codes must be 3-8 characters along with decimals

Codes must be 3 - 8 characters and 2 decimals.
Has the patient been using samples? Yes No
Dose and Directions: *

Required *
Enter Provider Information
Provider ID or NPI: *
Provider's Name: *
Physician's Specialty: *
Street Address: *
City: *
State: *
ZIP Code: *
Email Address:
Phone Number:
Enter a 10 digit phone number.
Fax Number:*
Enter a 10 digit phone number.
Contact First Name: *
Contact Last Name: *
Contact Email Address: *
Contact Phone Number: *
Contact Phone Ext:
Contact Fax Number:*

Drug Name/J-Code: *

Dyskinesia in Patients with Parkinson's Disease (PD).

Does patient meet ONE of the following? (A or B)

A. Initial Therapy. Does the patient meet the following criteria (i, ii, and iii):
Yes
No

i. Gocovri is prescribed by or in consultation with a neurologist; AND

Yes

No

ii. Patient is currently receiving levodopa-based therapy (e.g., carbidopa/levodopa); AND

Yes

No

iii. Patient has tried immediate-release amantadine capsules, tablets, or oral solution and meets ONE of the following criteria (a or b):

Yes

No

a) Patient derived benefit from IR amantadine but had intolerable adverse events, as determined by prescriber; OR *

Yes

No

b) Patient could not achieve a high enough dosage to gain adequate benefit, as determined by the prescriber. *

Yes

No

B. Patients Currently Receiving Gocovri. Does the patient meet the following criteria (i and ii):
Yes
No

i. Gocovri is prescribed by or in consultation with a neurologist; AND

Yes

No

ii. Patient is currently receiving levodopa-based therapy (e.g., carbidopa/levodopa); AND
Patient has had a response to therapy (e.g., decrease in dyskinesia), as determined by the prescriber. *

Yes

No

PLEASE SEND PROGRESS NOTES

If you are using a Specialty Pharmacy, please indicate which one will be providing the medication. *

Optum Specialty Services
Phone:855-427-4682
Fax: 800-218-3221

Other:

Select Optum or Other

Select Other Specialty Pharmacy

If service is not in your office please list the Infusion site or Facility/list ordering physician.

If you have any additional information pertinent to this patient's therapy, please specify.

Insert Attachments.

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please try again later.

Or, print the form and mail to:

Blue Cross and Blue Shield of Kansas City
Pharmacy Services
P.O. Box 412735
Kansas City, MO 64141-2735

Cancel

Revised 01/01/20

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.