800 551 5258-2026

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The document is a Prior Authorization Request Form for pharmacy services, intended for use by healthcare providers to obtain approval for medication prescriptions. It includes sections for patient and prescriber information, insurance details, diagnosis, and clinical justification. The form must be completed and faxed to the appropriate customer service numbers based on the patient's insurance plan, with a requirement for the prescriber's signature to process the request.

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Click ‘Get Form’ to open the Prior Authorization Request Form in the editor.
Begin by filling out the Patient Information section. Enter the patient's name, address, city, state, zip code, date of birth, and gender. Include an alternate contact's home phone and relationship to the patient.
Next, complete the Insurance Information section. Provide details for both primary and secondary insurance, including subscriber names and identification numbers.
In the Prescriber Information section, input the prescriber's name, phone number, office contact name, mailing address, fax number, DEA number, and license number.
Fill out the Diagnosis and Clinical Information area with primary and secondary ICD-9 codes along with medical justification for therapy initiation or continuation.
Complete the Prescription Information section by selecting prescription type (New Start or Continued Tx), entering medication requested, dosage details, quantity, and expected duration of therapy.
Finally, ensure that the prescriber signs and dates the form at the bottom before submitting it via fax to Pharmacy Customer Service.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Who is PBM for BCBS of MS?

CVS CAREMARK. CVS Caremark is the pharmacy benefit manager (PBM) for the Plans prescription drug program.

Does BCBS of MS pay for Wegovy?

A prior authorization ensures a drug is being prescribed safely and is of medical necessity. In most cases, your healthcare provider will initiate the prior authorization for Wegovy and will work with your BCBS plan to complete the request. If the prior authorization is approved, the medication will be covered.

What is the phone number for BCBS MS provider service?

If you are interested in our Blue Cross Blue Shield of Mississippi Clearinghouse services, please contact our Provider eSupport Services team at 601-664-4357.

Does Bluecross Blueshield cover Mounjaro?

Mounjaro (tirzepatide) may be prescribed if you have type 2 diabetes. Form Health physicians may choose to prescribe Mounjaro if you have a BMI of 30 or higher or 27 or higher with weight-related conditions, and you have not been successful in losing weight or maintaining weight loss with lifestyle changes alone.

How to get Mounjaro covered by insurance?

BCBS may cover Mounjaro, but it all depends on the specific plan. Some plans may list it as a preferred drug, while others list it as nonpreferred. Some might also have prior authorization requirements before theyll cover it. Without insurance or discounts, Mounjaro costs around $1,474 per month on average.

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How to get blue cross to approve Mounjaro?

How to Get Tirzepatide (Mounjaro) Coverage with Blue Cross Blue Shield Verify Prescription Eligibility. Review Your Blue Cross Blue Shield Plan. Contact Blue Cross Blue Shield Customer Service. Initiate Prior Authorization. Submit an Exception Request if Needed. Follow Up on Decision. Explore Additional Support Options.

How to get BCBS to approve Mounjaro?

Work with your healthcare provider to submit a prior authorization request if required. This usually involves filling out specific forms and providing medical documentation. Ensure that your provider includes all necessary information, such as your diagnosis, treatment history, and any other medications tried.