Prime Prior Authorization Form PDF Details

Navigating the complexities of healthcare requirements, the Prime Prior Authorization form emerges as a crucial document for patients and healthcare providers alike, particularly in the realm of ADHD medications. This specialized form, designed exclusively for physician use, demands completion and submission via fax, underscoring the importance of accurate and comprehensive information. It serves as a gatekeeper, ensuring that prescribed ADHD medications receive the necessary approval from insurance providers, in this instance, Blue Cross and Blue Shield of Illinois via Prime Therapeutics LLC. The form requires detailed patient information, insurance details, and thorough documentation from the prescribing physician, including patient diagnosis, the medication requested, and an overview of previous treatments. Additionally, it emphasizes the necessity of stating the rationale behind selecting the requested medication over other alternatives, taking into considerations such as contraindications, allergies, or adverse drug reactions. This request process not only facilitates a more informed decision-making process for insurance coverage but also highlights the collaborative effort between patients, healthcare providers, and insurers to optimize treatment outcomes. With confidentiality at its core, the form encapsulates the critical balance between patient privacy and the need for meticulous scrutiny in the preauthorization process.

QuestionAnswer
Form NamePrime Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesprimetherapeutics prior authorization forms for, prime therapeutics pa form, prime therapeutics fax number for prior authorization, prime prior authorization form

Form Preview Example

ADHD MEDICATIONS

PREAUTHORIZATION REQUEST

PHYSICIAN FAX FORM

ONLY the prescriber may complete and fax this form.

Incomplete forms will be returned for additional information. The following documentation is required for preauthorization consideration. For formulary information and to download additional forms, please visit WWW.BCBSIL.COM

Today’s Date:

PATIENT INFORMATION

Patient Name (First):

Last:

 

M:

DOB (mm/dd/yyyy):

 

 

 

 

 

Patient Address:

 

City, State, Zip

Patient Telephone:

 

 

 

 

 

INSURANCE INFORMATION

BCBS ID Number:

Group Number:

PHYSICIAN/CLINIC INFORMATION

Prescriber Name:

Physician NPI#:

Specialty:

Contact Name:

Clinic Name:

Clinic Address:

City, State, Zip:

Phone #:

Secure Fax #:

PLEASE ATTACH ANY ADDITIONAL INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST

Patient’s Diagnosis - ICD-9 code plus description:

Medication Requested:

Strength:

 

 

 

 

Dosing Schedule:

Quantity per Month:

 

 

 

 

1. Is the patient currently treated with the requested medication?

.......................................................... Yes

No

If yes, when was treatment with the requested medication started? _________________________

2.Please list all reasons for selecting the requested medication over alternatives (e.g. contraindications, allergies or history of adverse drug reactions.) __________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

3.Please list all other medications the patient is currently taking for treatment of this diagnosis. __________________

______________________________________________________________________________________________

______________________________________________________________________________________________

4.Please list any other medications the patient has previously tried and failed for treatment of this diagnosis. (Please specify if the patient has tried brand-name products, generic products or over-the-counter products.) ___________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Please fax or mail this form to:

Blue Cross and Blue Shield of Illinois

c/o Prime Therapeutics LLC, Clinical Review Department 1305 Corporate Center Drive

Eagan, Minnesota 55121

TOLL FREE

Fax: 877.480.8130

Phone: 800.285.9426

CONFIDENTIALITY NOTICE: This communication is intended only for the use of the individual entity to which it is addressed, and may contain information that is privileged or confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately by telephone at 800.858.0723, and return the original message to Blue Cross and Blue Shield of Illinois c/o Prime Therapeutics via U.S. Mail. Thank you for your cooperation.

6000 IL ADHD 0808

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

1009

an Independent Licensee of the Blue Cross and Blue Shield Association

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