PRECERTIFICATION REQUEST FORM
Fax completed form to 602-864-3126, or email to
[email protected].
Call 866-325-1794 to check the status of a request.
All fields must be completed and legible for review. Incomplete forms will be returned. Office notes, labs, and medical testing
relevant to the request that show medical justification are required. Pharmacy Coverage Guidelines are available at
www.azblue.com/pharmacy.
NON-LIFESCAN BLOOD GLUCOSE METER TEST STRIPS
Section 1: Prescribing Provider Information
Name:
Specialty:
NPI:
Address:
Phone:
Fax:
Section 2: Patient Information
First & Last Name:
Email:
Date of Birth:
This form does not apply to FEP or other states’ Blues Plans ►
Gender:
BCBSAZ ID:
Male
Female
Group ID:
Section 3: Blood Glucose Test Strip and Meter Information
Name:
Directions:
Duration of Use:
ICD-10 Code:
Diagnosis Description:
Lifescan brand blood glucose test strips do NOT require precertification (prior authorization) under the
BCBSAZ Pharmacy Benefit, but other prescription limitations do apply (e.g. quantity)
Section 4: All questions must be answered and all relevant information must be provided to assess request
1.
Yes
No
Is the individual unable to use features of the preferred Lifescan product?
2.
Yes
No
Does the non-preferred meter have additional feature(s) not found on preferred Lifescan product?
3.
Yes
No
Does the individual use an insulin pump system where the pump is controlled by a non-preferred
meter?
Yes
No
Office notes, labs, and medical testing relevant to the request that show medical justification are
required. I have sent this medical information with this form to validate all relevant data presented.
4.
.
Section 5: Signature affirms that information given on this form is true and accurate and reflects office notes
Prescribing Provider’s Signature:
Date:
Section 6: Turn-Around Time For Review (check one)
Standard
Urgent
Exigent (requires prescriber to include a written statement)
Blue Cross Blue Shield of Arizona, Mail Stop A115, P.O. Box 13466, Phoenix, AZ 85002-3466
Effective:
10/01/13
Revised:
11/17/16
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