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.

Form NamePrime Prior Authorization Form
Form Length1 pages
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




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 Name (First):




DOB (mm/dd/yyyy):






Patient Address:


City, State, Zip

Patient Telephone:







BCBS ID Number:

Group Number:


Prescriber Name:

Physician NPI#:


Contact Name:

Clinic Name:

Clinic Address:

City, State, Zip:

Phone #:

Secure Fax #:


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

Medication Requested:






Dosing Schedule:

Quantity per Month:





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

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


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


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,


an Independent Licensee of the Blue Cross and Blue Shield Association

How to Edit Prime Prior Authorization Form Online for Free

Using the online PDF tool by FormsPal, you are able to fill in or alter prime therapeutics pa form here and now. Our team is dedicated to giving you the best possible experience with our editor by constantly adding new functions and enhancements. With these updates, using our editor gets easier than ever before! This is what you will need to do to get going:

Step 1: Click the "Get Form" button above. It is going to open our pdf tool so that you can begin completing your form.

Step 2: With our online PDF file editor, you could accomplish more than just fill in blank form fields. Edit away and make your docs seem faultless with customized text incorporated, or adjust the file's original content to excellence - all that comes with an ability to insert just about any graphics and sign the document off.

As for the fields of this specific document, here's what you want to do:

1. When submitting the prime therapeutics pa form, ensure to complete all of the important blank fields within the corresponding part. This will help to facilitate the work, which allows your details to be processed without delay and appropriately.

The best ways to fill out prime therapeutics prior authorization forms portion 1

Step 3: Prior to finalizing the document, it's a good idea to ensure that form fields have been filled in as intended. Once you confirm that it's good, click on “Done." Make a 7-day free trial subscription at FormsPal and gain immediate access to prime therapeutics pa form - with all changes saved and available inside your FormsPal cabinet. FormsPal is dedicated to the privacy of all our users; we ensure that all information used in our system is protected.