Highmark blue cross blue shield medication prior authorization forms

Highmark Blue Shield's Preferred Method for Prior Authorization Requests

Our electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible.

Improving efficiencies without sacrificing the essentials

• 70%1 of users reported time savings
• 35%2 faster determinations than phone or fax
• HIPAA compliant and available for all plans and all medications
• No cost to providers and their staff

1 - CoverMyMeds Provider Survey, 2019

2 - Express Scripts data on file, 2019

Updated June 02, 2022

A Highmark prior authorization form is a document used to determine whether a patient’s prescription cost will be covered by their Highmark health insurance plan. A physician must fill in the form with the patient’s member information as well as all medical details related to the requested prescription. Once the form is complete, send it by fax or mail to the appropriate addresses below.

• Fax: 1 (866) 240-8123
• Mail: Medical Management & Policy, 120 Fifth Avenue, MC P4207, Pittsburgh, PA 15222

How to Write

Step 1 – In “Patient Information”, supply the patient’s subscriber ID number, Highmark coverage group number, full name, phone number, date of birth, and full address.

Step 2 – In “Clinical / Medical Information”, specify the drug name, strength or dose, requested quantity per month, diagnosis, name of the carrier who paid for the most recent transplant, type of transplant, date of most recent transplant, and the most recent transplant payer.

Step 3 – In “Alternatives Tried / Used By Patient (if applicable)”, specify the following information regarding any alternative drugs tried by the patient: drug name, strength, and documentation of failure of therapy.

Step 4 – In “Medical Rationale / Reason for Drug Therapy / Treatment Plan”, provide any additional information to support the request.

Step 5 – In “Physician Information”, provide the physician’s name, NPI or Tax ID number, phone number, fax number, and full address. The physician will also need to provide their signature and the date.

Step 6 – Lastly, specify the medicare type, commercial type, and request type.

Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.

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