Site of Care Authorization

Blue KC has implemented a medical policy to require administration of certain medications in the most cost-effective site of care that is clinically appropriate for a member’s condition. This drug must NOT be billed as an outpatient hospital facility place of service.

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* Required Field

Enter Patient Information

  • Drug Name:*
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • IDC-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.
  • Has the patient been using samples?
  • Yes No
  • Dose and Directions: *

* Required Field

Enter Provider Information

  • Provider ID OR NPI: *
  •  
    • I am an Ordering Physician
    • I am a Servicing Physician
    • I am an Infusion Provider
  • Ordering Physician's Name:
  • Ordering Physician's Address:
  • Ordering Physician's City:
  • Ordering Physician's State:
  • Ordering Physician's Zip:
  • Ordering Physician's Email Address:
  • Ordering Physician's Phone No:
  • Ordering Physician's Fax No:
  • Servicing Physician's Name:
  • Servicing Physician's Address:
  • Servicing Physician's City:
  • Servicing Physician's State:
  • Servicing Physician's Zip:
  • Servicing Physician's Email Address:
  • Servicing Physician's Phone No:
  • Servicing Physician's Fax No:
  • Infusion Provider's Name:
  • Infusion Provider's Address:
  • Infusion Provider's City:
  • Infusion Provider's State:
  • Infusion Provider's Zip:
  • Infusion Provider's Email Address:
  • Infusion Provider's Phone No:
  • Infusion Provider's Fax No:
  • Contact First Name:*
  • Contact Last Name:*
  • Contact Email Address:*
  • Contact Phone No:*
  • Contact Phone Ext:
  • Contact Fax No:*

J Code: *

Will services be provided in the home? *

  • Yes No

If you have clinical rationale as to why this should be done in an Out Patient Hospital FACILITY, please provide it and the complete name and address of that facility.

Previous/current drug therapies tried and failed: *

  • lbs.
  • mg/kg

If using a Specialty Pharmacy, please indicate which one.

  • Accredo
    Phone: 877-259-2295
    Fax: 888-773-7386
  • Hospital
  • Buy and Bill
  • Other
Please Select a Pharmacy.

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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

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Revised 06/01/18

Member Prefix

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.

ID Number

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.

Suffix

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.

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