Prime Prior Authorization Form PDF Details

The healthcare industry has become increasingly complicated over the years, and the need to understand when and how certain processes are used can be daunting. One such process is Prime Prior Authorization: a formal request from your doctor, on your behalf, for insurance coverage of prescribed treatments. In this blog post we'll explain what Prime Prior Authorization Forms are, why they're important and how to ensure your form is accurately filled out so that you have no delays in getting the care you need. Keep reading if you would like to gain an understanding of this important tool for navigating modern healthcare services!

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

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