Prior Authorization Other Specialty Medications

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* Required Field

Enter Patient Information

  • Drug Name: *
  • Review Type: *
  • Expedited Requests should be reserved for cases when you are able to attest that the member's health or life could be in jeopardy if the standard timeframe is applied.
  •  
  • Standard
    Expedited
  • Blue KC ID (Not SS#): *
  • - -
  • 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
  • Is this a transition of care request as defined by Medicare: *
  • Yes
    No
  • Dose of Drug Being Used: *
  • Frequency/Directions of Drug being Used: *
  • Expected Date of Service: *
  • Length of Time Needed:*
  •  
  • Start Date:*
  • End Date:*

* Required Field

Enter Provider Information

  • Requesting Physician/
    Provider Name: *
  • Requesting Physician/
    Provider NPI: *
  •   
  • Requesting Physician's
    Address: *
  • Requesting Physician's City:*
  • Requesting Physician's State: *
  • Requesting Physician's Zip: *
  • Requesting Physician's Phone Number:
  • Enter a 10 digit phone number.
  • Requesting Physician's Fax Number: *
  • Enter a 10 digit phone number.
  • Servicing Physician/
    Provider Name: *
  • Servicing Physician/
    Provider NPI: *
  • Servicing Physician's Address: *
  • Servicing Physician's City: *
  • Servicing Physician's State: *
  • Servicing Physician's Zip: *
  • Servicing Physician's Phone Number: *
  • Servicing Physician's Fax Number: *
  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address: *
  • Contact Phone Number: *
  • Contact Phone Ext:
  • Contact Fax Number: *

Drug Name and J-Code: *

Previous medications tried and failed with dates: *

Physician Specialty:*

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

All Specialty medications must be provided by one of the following: *

  • Buy and Bill
  • Other:
Select Buy and Bill or Other
Select Other Specialty Pharmacy

If you have any additional information pertinent to this patient's therapy, please specify. Please attach any additional information to support the use of medications (Ex: Treatment plan, clinical documentation, lab results, etc.).

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

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Revised 12/19/23

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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