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All Medicare Plus Blue members have coverage for transplant procedures that are covered by traditional Medicare.

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Destination — Where this form is being submitted to; payers making this form available on their websites may prepopulate section A Health Plan or Prescription Plan Name: Health Plan Phone: Fax: B.

Updates to the list of drugs and supplies. Some procedures may also receive instant approval.

Some procedures may also receive instant approval.

For some services listed in our medical policies, we require prior authorization.

. Patient Information Patient Name: DOB: Gender: ☐ Male Female ☐ Unknown Member ID #: C. m.

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Prescriber Information Prescribing Clinician: Phone #:. Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Prior Approval Page; Formulary Exception Form.

Questions?. Medical Record Routing Form (PDF) Download.

providerportal.

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To request prior authorization using the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm), click the link below:. .

, an Independent Licensee of the Blue Cross Blue Shield Association.
©1998-BlueCross BlueShield of Tennessee, Inc.
The Mass Collaborative’s primary focus is on improving how providers and payers interact with each other.

Please read Section 3 for more information about prior approval.

Home Infusion Therapy Prior Authorization Form.

. m. Resistant Depression Prior Authorization Request Form Medical Policy #087 Esketamine Nasal Spray (SpravatoTM) and Intravenous Ketamine for Treatment-Resistant Depression Please use this form to assist in identifying members who meet Blue Cross Blue Shield of Massachusetts’ (BCBSMA’s) medical necessity criteria for Esketamine Nasal Spray.

Some procedures may also receive instant approval. Patients must. . By fax: Request form. Artificial Pancreas Device Systems Prior Authorization Request Form #845 Medical Policy #107 Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems Please use this form to assist in identifying members who meet Blue Cross Blue Shield of Massachusetts’.

Prior Approval Page; Formulary Exception Form.

Destination — Where this form is being submitted to; payers making this form available on their websites may prepopulate section A Health Plan or Prescription Plan Name: Health Plan Phone: Fax: B. To request prior authorization for these medications, please submit the: Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or contact Clinical Pharmacy Operations.

Please read Section 3 for more information about prior approval.

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Physicians may also call BCBSMA Pharmacy Operations department at (800)366-7778 to request a prior authorization/formulary exception verbally.

The Formulary Exception process allows members to apply for coverage of a non-covered drug if they have tried and failed the covered drug(s).