800-437-3803

Other daignossi (please specify): _____ . 2 . Has the pateint faelid to acheive an adequaet response to 2 or more of the fooll wni g conse rvatvi e non -pharmacologic therapy below?

(800) 437-3803 Generic drugs $5 copay/retail No charge/mail order 25% of the approved amount, after the $5 copayment Prescription Drug Benefits are available only for Active Participants, COBRA Participants, and non-bargaining unit Participants. Non-Medicare Eligible Retirees and their Dependents are not eligible for Prescription Drug Benefits.1-800-437-3803 to obtain PA and ST requirements and forms. Walgreens Specialty Pharmacy provides specialty drugs to BCN members in Michigan. All drugs shipped into Michigan billed by other specialty pharmacies require authorization. Durable medical equipment purchased in or shipped to Michigandays per week, at 1-800-437-3803 to obtain PA and ST requirements and forms. Walgreens Specialty Pharmacy provides specialty drugs to BCN members in Michigan. All drugs shipped into Michigan billed by other specialty pharmacies require prior authorization. Durable medical equipment purchased in or shipped to Michiganthe Pharmacy Clinical Help Desk at 1-800-437-3803. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID number : Specialty Date of birth . Male Female . Address Diagnosis (include ICD-10) City/State/Zip Drug name Phone: ( ) - Fax: ( ) - Dose and quantity ...By Mail: BCBSM Specialty Pharmacy Program : P.O. Box 312320, Detroit, MI 48231- 23201-800-811-1764 to enroll. Blue Care Complete Preferred Drug List . ... for these medications, contact the BCN Clinical Pharmacy Help Desk at 1-800-437-3803. This number is available to providers 24 hours a day, seven days a week, including holidays.For Medicare Plus Blue SM and BCN Advantage SM members: Call the Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Clinical Help Desk at 1-800-437-3803. To determine which drugs this applies to, see the following drug lists: Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial ...

Phone: (800) 437-3803 BCBSM Fax: (866) 601-4425 BCN Fax: 877-442-3778. Office Contact: . Tech/Date/Time: Request for expedited review By checking this box, I certify that applying the standard review time frame may seriously jeopardize the life or health of the member or the member’s ability to regain maximum function.Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION . PHYSICIAN INFORMATION Name . Name ID Number ; Specialty D.O.B. Male Female . Address Diagnosis . City /State/Zip Drug Name Phone/Fax: P: ( ) - F: ( ) - Dose and Quantity ...Other ways to submit a request Calling 1-800-437-3803. Faxing BCBSM at 1-866-601-4425. Faxing BCN at 1-877-442-3778. Writing: Blue Cross Blue Shield of Michigan, Pharmacy Services. Mail Code 512. Detroit, MI 48226-2998. How do I appeal a Blue Cross complete of Michigan provider?Request for Medicare Prescription Drug Coverage DeterminationChart notes are required for the processing of all requests. Please add any other supporting medical information necessary for our reviewor the Medical Drug Helpdesk at 1 -800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name ; Name ID Number . Specialty D.O.B. Pt weight (in kg) Date . Male Female . recorded:_____ Address Diagnosis . City /State/Zip Drug Name . Phone/Fax: P ...Medical Drug Helpdesk at 1 -800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number . Specialty D.O.B. Weight (kg): Male Female . Date recorded:_____ Address Diagnosis . City /State/Zip Drug Name . Phone/Fax: P ...Abuse Precertification: 800-762-2382 Rx Claims/Rx PriorAuth. 800-437-3803 ... Phone number: 1-800-437-3803 Fax: 1-866-601-4425 Mail: BCBSM Clinical Help Desk P.O. Box 312320 Detroit MI, 48231 W009604 bcbsm.com. Title: Save time and submit your prior authorization requests electronically for pharmacy benefit drugs

800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION . Name Name ID Number . Specialty D.O.B. Male Female . Address Diagnosis . City /State/Zip Drug Name : Zolgensma. Phone/Fax: P: ( ) - F: ( ) - Dose and Quantity . NPI ...For questions about utilization management requirements, call the Blue Cross / BCN Pharmacy Clinical Help Desk at 1-800-437-3803. For questions about the CoverMyMeds web tool, call the CoverMyMeds support center at 1-866-452-5017. *Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website.• Medical authorization: 1-800-392-2512 • Pharmacy prior authorization: 1-800-437-3803 • Process claims through your local Blue Cross Blue Shield plan. Provider Inquiry Physicians/professionals: 1-800-344-8525 Hospitals/facilities: 1-800-249-5103 When you receive health care servicesAddress: Blue Cross Blue Shield of MI Clinical Pharmacy Help Desk – C303 PO Box 807 Southfield, MI 48037 Fax Number: 1-866-601-4428 You may also ask us for an appeal through our website at www.bcbsm.com/medicare/grievances-appeals.shtml. Expedited appeal requests can be made by phone at 1-800-437-3803.Pharmacies with questions about AWP or MAC pricing should contact BCBSM's Technical Pharmacy Help Desk at 1-800-437-3803. Dental disputes. Call 1-844-876-7917, 8 a.m. to 7 p.m. Eastern time, Monday through Friday Automated information is available 24/7

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Medical Drug Helpdesk at 1 -800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number ; Specialty D.O.B. Pt weight (in kg) Date recorded:_____ Male Female . Address Diagnosis . City /State/Zip Drug Name ; Phone/Fax: P ...1-800-437-3803 : Services that require authorization for Michigan providers For Medicare Plus BlueSM members Updated March 2022. 5 . Changes from the previous publication are identified by a Blue Dot and explained on the final page of this document.Changes from previous publication are marked with a Blue Dot and explained on the final page of ...Instead, call the Pharmacy Clinical Help Desk at 1-800-437-3803. Log in to our provider portal (availity.com*). Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo. In the Applications tab, click the Carelon ProviderPortal tile. Select an organization (if appropriate), select a provider and click Submit.If you have any questions regarding this process, please contact BCBSM Provider Relations and Servicing or the Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMA TION PHYSICIAN INFORMATION1 800 437 3803 form; Paypal payment receipt pdf form; Wofbi form; Mankind the story of all of us episode 2 worksheet answers form; From critical thinking to argument pdf form; Peap aca order form; Target punch correction form; Hmsa travel request form; Show more. Find out other King Cooperative.

Phone: (800) 437-3803 BCBSM Fax: (866) 601-4425 BCN Fax: 877-442-3778. Office Contact: . Tech/Date/Time: Request for expedited review By checking this box, I certify that applying the standard review time frame may seriously jeopardize the life or health of the member or the member's ability to regain maximum6 . What is the pateint's daignossi? Fetal Alloimmune Thrombocytopenia (F/NAIT) Multiple sclerosis Inclusion-body myositis Parvovirus B 19-induced Pure Red Cell Aplasia (PRCA)Blue Cross Blue Shield/Blue Care Network of Michigan Medication Authorization Request Form. Confidentiality notice: This transmission contains confidential information belonging to the sender that is legally privileged.For questions about utilization management requirements, call the Blue Cross / BCN Pharmacy Clinical Help Desk at 1-800-437-3803. For questions about the CoverMyMeds web tool, call the CoverMyMeds support center at 1-866-452-5017. *Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website.process, please contact BCBSM/BCN at (800) 437-3803. Important information about Blue Cross and Blue Care Network plan approved quantity limits: BCBS M /BCN Standard /Custom Select Plan Limits If you have any questions regarding this process, please contact BCBSM Provider Relations and Servicing or the Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMA TION PHYSICIAN INFORMATIONPlease contact BCN Specialty Pharmacy Helpdesk at 1-800-437-3803 with any questions. Instructions: This form may be used by participating physicians and providers to request clinical review for drugs covered under the medical benefit for BCN HMO and BCN Advantage members.Medical Drug Helpdesk at 1-800-437-3803 for asssi tance. PATIENT INFORMATION PHYSICIAN INFORMATION . Name Name SpecialtyID Number ; Address. D.O.B. Male Female . City /State/Zip. Diagnosis . Phone: Drug Name . Fax: Dose and Quantity ; NPI . Contact PersonDirections . Date of Service(s) Contact Person Phone / Ext.800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number ; Specialty D.O.B. Pt weight (in kg) Male Female . Date recorded:_____ Address Diagnosis ; City /State/Zip Drug Name . Phone/Fax: P: ( ) - F ...Confidentiality notice: This transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party.If you have any questions regarding this process, please contact BCBSM Provider Relations and Servicing or the Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION

How to create an eSignature for the 1 800 437 3803. ... State of Michigan MIChild Customer Service at 1-800-543-7765. You can take your child to any dentist in our PPO network. To find one near you, visit our website at bcbsm.com. Benefit Information 01/01/2018 (if applicable) ...

Blue Cross Complete Prior Authorization Request Attn: Blue Care Network Clinical Pharmacy Help Desk Mail Code C303 20500 Civic Center Drive, Southfield, MI 48076 Phone: 1-800-437-3803 Fax: 1-877-442-37781-800-437-3803 8 a.m. to 6 p.m. Monday through Friday. Optum Rx ® help desk. 1-800-788-4863. Submit prior authorization requests electronically through CoverMyMeds.Pharmacies with questions about AWP or MAC pricing should contact BCBSM's Technical Pharmacy Help Desk at 1-800-437-3803. Dental disputes Call 1-844-876-7917, 8 a.m. to …Capitated laboratory program: Call Quest Diagnostics at 1-866-697-8378. Pharmacy services Pharmacy Clinical Help Desk and prior authorizations: Call 1-800-437-3803. Walgreens Specialty Pharmacy: Call 1-866-515-1355. Express Scripts : Call 1-800-922-1557.Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION . PHYSICIAN INFORMATION Name . Name ID Number ; Specialty D.O.B. Male Female . Address Diagnosis . City /State/Zip Drug Name Phone/Fax: P: ( ) - F: ( ) - Dose and Quantity ...800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number . Specialty D.O.B. Pt weight (in kg) Male Female . Date recorded:_____ Address Diagnosis . City /State/Zip Drug Name . Phone/Fax: P: ( ) - F ...Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION. PHYSICIAN INFORMATION ; Name Name ID Number . Specialty D.O.B. Male Female Address Diagnosis . City /State/Zip Drug Name : EXONDYS 51 Phone: Fax: Dose and Quantity . NPI Directions : Contact Person Date of Service(s) ...Servicing or the Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name : Name ID Number : Specialty D.O.B. Male Female : Addr ess Diagnosis : City /State/Zip Drug Name ; Phone/Fax: P: ( ) - F ...Highmark BCBS of Pennsylvania (PA) Western region Professional: 800-547-3627. Highmark Blue Shield (BS) of Pennsylvania (PA) Western region Facility: 800-242-0514. Central and Northeastern region Professional: 866-731-8080. Central and Northeastern region Facility: 866-803-3708.

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Prepare your docs in minutes using our straightforward step-by-step guideline: Get the 800 437 3803 you want. Open it using the online editor and begin adjusting. Fill out the blank fields; involved parties names, addresses and numbers etc. Customize the blanks with exclusive fillable fields. Put the day/time and place your electronic signature.Midland Credit Management If you are receiving calls from one of the numbers below, you are being called by Asset Acceptance, a debt collector. Asset Acceptance is a large collection agency that not only collects debts for creditors but also buys debts to collect themselves. Located in eastern Michigan, Asset Acceptance has participated in collections allCapital City Police. UAN: 15 Phone: 042-99202976 Lahore Waste Management Company. UAN: 1139 Phone: 042-99205153 - 55 Water and Sanitation Agency (WASA) Central …the Pharmacy Clinical Help Desk at 1-800-437-3803. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID number : Specialty Date of birth . Male Female . Address Diagnosis (include ICD-10) City/State/Zip Drug name Phone: ( ) - Fax: ( ) - Dose and quantity ...any questions regarding this process, contact the Pharmacy Clinical Help Desk at 1-800-437-3803. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number : Specialty D.O.B. Male Female . Address Diagnosis (include ICD-10) City /State/Zip Drug Name Phone ...Page 1 of 3 1 Request for Medicare Prescription Drug Coverage Determination Requests for coverage determination can also be made by phone at 1-800-437-3803 or at https://www.Blue Cross Blue Shield /Blue Care Network of Michigan Medication Authorization Request Form. Required Demographic Information: Patient Weight:Clinical help desk at (800) 437-3803. This will reduce waiting time in the pharmacy on your part and prevent you from paying out-of-pocket for medications that should be covered as a part of your prescription program. Specialty Prescription Program Specialty drugs are prescription medications that require• Call: 1-800-437-3803 Blue Cross Pharmacy ; Benefit Drugs on page. ereferrals.bcbsm.com. Alacura Medical Transport . Non-emergency air ambulance flights ;1-800-437-3803. Their hours are Monday through Friday from 9 a.m. to 4 p.m. Eastern time. Note: To determine which vendor manages authorizations for specific procedures and services, see the . Summary of utilization management programs for Michigan providers. Behavioral health codes (mental health and substance use disorders) Code listBlue Cross Complete Prior Authorization Request Attn: Blue Care Network Clinical Pharmacy Help Desk Mail Code C303 20500 Civic Center Drive, Southfield, MI 48076 Phone: 1-800-437-3803 Fax: 1-877-442-3778 ….

BCN Advantage 1-800-459-8027 Clinical Pharmacy Help Desk - C303 PO Box 807 Southfield, MI 48037 ... Expedited appeal requests can be made by phone at 1-800-437-3803. ...Jul 13, 2017 · Report the unwanted call to the FTC as soon as possible. If you want to report an unwanted sales calls coming from an actual human being, you must have been on the Do Not Call Registry for at least 31 days beforehand. For robocalls, however, you can report the call immediately, whether or not you are on the registry. Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number ; Specialty D.O.B. Male Female . Address Diagnosis / ICD-9 . City /State/Zip Drug Name . Phone/Fax: P: ( ) - F ...Blue Cross Blue Shield /Blue Care Network of Michigan Medication Authorization Request Form. Required Demographic Information: Patient Weight:1 800 437 3803 form; Paypal payment receipt pdf form; Wofbi form; Show more. Find out other Order Appointing Guardian. How Do I Electronic signature North Carolina Follow-Up Letter To Customer; How Do I Electronic signature Wyoming Sales Proposal Template;1-800-437-3803. Their hours are Monday through Friday from 9 a.m. to 4 p.m. Eastern time. Note: To determine which vendor manages authorizations for specific procedures and services, see the . Summary of utilization management programs for Michigan providers. Behavioral health codes (mental health and substance use disorders) Code list June 2017. For BCN and Blue Cross Medicare Plus Blue PPO, use 1-800-437-3803 to reach the Pharmacy Clinical Help Desk. Submit only the pertinent medical records for BCN initial inpatient admission requests. Register now for July e-referral training webinars for Blue Cross authorization requests. Reminder: Effective July 1, additional medical ...Servicing or the Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number ; Specialty D.O.B. Pt weight (in kg) Male Female . Date recorded:_____ Address Diagnosis ; City /State/Zip Drug Name . Phone/Fax: P ... 800-437-3803, Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION : Name Name ID Number : Specialty D.O.B. Male Female Address Diagnosis . City /State/Zip Drug Name : Phone/Fax: P: ( ) - F ..., Blue Cross Blue Shield/Blue Care Network of Michigan Medication Authorization Request Form. Confidentiality notice: This transmission contains confidential information belonging to the sender that is legally privileged., any questions regarding this process, contact the Pharmacy Clinical Help Desk at 1-800-437-3803. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number : Specialty D.O.B. Male Female . Address Diagnosis (include ICD-10) City /State/Zip Drug Name Phone: ( ) - Fax: ( ) - Dose and Quantity . NPI Directions : Contact Person Date of ..., Phone: (800) 437-3803 BCBSM Fax: (866) 601-4425 BCN Fax: 877-442-3778. Office Contact: . Tech/Date/Time: Request for expedited review By checking this box, I certify that applying the standard review time frame may seriously jeopardize the life or health of the member or the member’s ability to regain maximum function., about utilization management requirements, call the Blue Cross / BCN Pharmacy Clinical Help Desk at 1-800-437-3803. For questions about the CoverMyMeds web tool, call the CoverMyMeds support center at 1-866-452-5017. *Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While, 1-800-437-3803 to obtain PA and ST requirements and forms. Walgreens Specialty Pharmacy provides specialty drugs to ... Laboratory services: Contact JVHL at 1-800-445-4979, for genetic testing and for laboratory services performed by an independent clinical laboratory, if the specimen was obtained in Michigan. ..., About Metalcraft. Metalcraft has provided property identification solutions since 1950. What began as a solution for the Bostitch Stapler Company's identification needs has evolved into Metalcraft as we know it today, a strong, innovative, growing company living by our corporate values and driven by the Metalcraft Compass. As member-owners we ..., Hours: 8:00-Noon 1:00-5:00 p.m. Monday through Friday Center staff is on 24 hour call for emergency cases, Pharmacy Clinical Help Desk at 1-800-437-3803. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID number . Specialty Date of birth . Male Female Address Diagnosis : City/State/Z IP Drug name/HCPCS code . Phone: ( ) - Fax: ( ) - Dose and quantity . NPI Directions . Contact person Date of services : Contact person’s, questions regarding this process, please contact BCBSM Provider Relations and Servicing or the Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION, 1 800 437 3803 form; Paypal payment receipt pdf form; Wofbi form; Show more. Find out other Order Appointing Guardian. How Do I Electronic signature North Carolina Follow-Up Letter To Customer; How Do I Electronic signature Wyoming Sales Proposal Template;, Pharmacy Clinical Help Desk at 1-800-437-3803. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID number . Specialty Date of birth . Male Female Address Diagnosis : City/State/Z IP Drug name/HCPCS code . Phone: ( ) - Fax: ( ) - Dose and quantity . NPI Directions . Contact person Date of services : Contact person's, si the patein ut nabel to toelrant or have a conrtani d ication to conventional Crohn's disease therapy and TNF ni hbi tiors? Yes No, For more information on appointing a representative, contact your plan or Medicare at 1-800-MEDICARE , TTY users call 1-877-486-2048, 24 hours a day, 7 days a week. Name of prescription drug you’re requesting (if known, include strength and quantity requested per month): £ I need a drug that isn’t on the plan’s list of covered drugs., • Call: 1-800-437-3803 Blue Cross Pharmacy ; Benefit Drugs on page. ereferrals.bcbsm.com. Alacura Medical Transport . Non-emergency air ambulance flights ;, Pharmacy Clinical Help Desk at 1-800-437-3803. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID number . Specialty Date of birth . Male Female Address Diagnosis : City/State/Z IP Drug name/HCPCS code . Phone: ( ) - Fax: ( ) - Dose and quantity . NPI Directions . Contact person Date of services : Contact person's, If you have any questions regarding this process, contact the Pharmacy Clinical Help Desk at 1-800-437 -3803. PATIENT INFORMATION. PHYSICIAN INFORMATION Name . Name ID Number . Specialty D ate of birth : Male Female . Address Diagnosis (include ICD-10) City /State/Zip Drug Name Phone: ( ) - F. ax: ( ) - Dose and Quantity . NPI ..., Eastpointe Community Schools | 2 2022 Benefit Guide Eastpointe Community Schools offers you and your eligible family members a comprehensive and valuable benefits program., process, please contact BCBSM Provider Relations and Servicing or the Medical Drug Helpdesk at 1 -800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number ; Specialty D.O.B. Male Female . Address Diagnosis . City /State/Zip Drug Name . Phone/Fax: P ..., Blue Cross Blue Shield/Blue Care Network of Michigan Medication Authorization Request Form. Required Demographic Information: Patient Weight: _____ kg, days per week, at 1-800-437-3803 to obtain PA and ST requirements and forms. Walgreens Specialty Pharmacy provides specialty drugs to BCN members in Michigan. All drugs shipped into Michigan billed by other specialty pharmacies require prior authorization. Durable medical equipment purchased in or shipped to Michigan Elective (non …, Medical Drug Helpdesk at 1 -800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number . Specialty D.O.B. Pt weight (in kg) Date . Male Female . recorded:_____ Address Diagnosis . City /State/Zip Drug Name . Phone/Fax: P ..., Contact the Pharmacy Clinical Help Desk at 1-800-437-3803 and follow the prompts for physician-administered drugs. How do I obtain retroactive authorizations for services already provided? To request retroactive authorization after you provide services, contact the Pharmacy Clinical Help Desk at 1-800-437-3803., Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION. PHYSICIAN INFORMATION . Name Name ID Number . Specialty D.O.B. Male Female . Address Diagnosis . City /State/Zip Drug Name . Phone/Fax: P ..., Servicing or the Medical Drug Helpdesk at 1-800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name . Name ID Number ; Specialty D.O.B. Pt weight (in kg) Male Female . Date recorded:_____ Address Diagnosis ; City /State/Zip Drug Name . Phone/Fax: P ..., If you have any questions regarding this process, contact the Pharmacy Clinical Help Desk at 1-800-437-3803. PATIENT INFORMATION PHYSICIAN INFORMATION Name ; Name ID Number . Specialty D ate of birth : Male Female . Address Diagnosis (include ICD-10) City /State/Zip Drug Name Phone: ( ) - F. ax: ( ) - Dose and Quantity ..., Other ways to submit a request Calling 1-800-437-3803. Faxing BCBSM at 1-866-601-4425. Faxing BCN at 1-877-442-3778. Writing: Blue Cross Blue Shield of Michigan, Pharmacy Services. Mail Code 512. Detroit, MI 48226-2998. , Service Contact Information Behavioral health For Federal Employee Program members, call 1-800-342-5891 to refer for care. For MESSA members, call 1-800-336-0022 to refer for care. For all other members, call New Directions at 1-800-762-2382 to refer for care. Call PARS for all member-benefit-related questions: Professional providers, call 1 ..., 800-437-3803 for assistance. PATIENT INFORMATION PHYSICIAN INFORMATION Name Name ID Number Specialty D.O.B. Male Female Address Diagnosis City /State/Zip Drug Name Zolgensma Phone/Fax: P: ( ) - F ..., Your doctor can request prior authorization electronically or by calling our Pharmacy Help Desk at 1-800-437-3803. They can use those same methods to request a coverage review. You can also look on your plan’s drug list (a list of approved medications)., Help For Providers: How Do I Submit Prior Authorization Requests for Drugs? To help make sure Blue Cross Blue Shield of Michigan and Blue Care Network members receive the most appropriate and cost-effective therapy, we require providers to take additional steps before certain drugs are eligible for reimbursement. Prior authorization requirements, Confidentiality notice: This transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party., under the Resources tab to get to our You can also call 1-800-437-3803 for the Pharmacy provider alerts. Affirmation statement about incentives Utilization decisions about care and service are based solely on the appropriateness of care prescribed in relation to each member's medical or behavioral health condition and existence of coverage.