Prime Therapeutics Prior (Rx) Authorization Form

Updated January 24, 2022

Prime Therapeutics prior authorization form, also known as a Formulary Exception Form, is used to request coverage for a patient’s prescription that isn’t listed on their health insurance provider’s formulary. This document will contain the diagnosis and an explanation for why the prescription is suggested above those which are potentially more commonly used. On this page, you will find a fillable PDF version of this form which you can download, as well as the fax number that you must send it to.

How to Write

Step 1 – Begin filling out the form by providing the patient’s full name, date of birth, complete address, and telephone number into the appropriate fields of the Patient Information section.

Step 2 – In Insurance Information, enter the BCBS ID number and group number.

Step 3 – Next, in Physician/Clinic Information, you must provide your full name, your NPI number, your specialty, an office contact name, your clinic’s name, your clinic’s complete address, your clinic’s phone number, and your clinic’s fax number.

Step 4 – Below the above sections, there is a notice telling you to attach any additional information that should be considered with this request. This could be laboratory or trial results relevant to this diagnosis. Fax these documents along with this form once it has been filled.

Step 5 – You must then enter the patient’s relevant diagnosis, the name, strength, and dosing schedule, and quantity per month of the requested medication.

Step 6 – Indicate whether the patient is currently being treated with the requested medication, and if so, what the starting date of the treatment was. You will then need to provide your justification for making this request, list all other medications that the patient is taking, as well as any medications that the patient has tried and failed, for treatment of this diagnosis.