Prime therapeutics prior authorization form 2025

1. Click ‘Get Form’ to open the prime therapeutics prior authorization form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's first and last name, address, date of birth, and telephone number.
3. Next, complete the 'Insurance Information' section by providing the BCBS ID number and group number.
4. In the 'Physician/Clinic Information' section, input your name, NPI number, specialty, clinic name, address, phone number, contact name, and secure fax number.
5. Attach any additional documentation that should be considered with this request. Fill in details about the patient's diagnosis including ICD-9 code and description.
6. Specify the medication requested along with its strength, dosing schedule, and quantity per month.
7. Answer questions regarding current treatment with the requested medication and provide reasons for selecting it over alternatives.
8. List all other medications currently taken by the patient as well as any previously tried medications that were ineffective.
9. Once completed, review all entries for accuracy before submitting via fax or mail to Blue Cross and Blue Shield of Illinois.

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