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It defines prior authorization, clarifies provider and prescription terminology, and explains insurer response timelines for standard versus expedited review. The form covers submission and contact routing to the patient’s health plan, patient demographics, provider and pharmacy information, requested drug details, rationale, failed therapies, and additional optional supporting 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ILCS 5/364.3 requires the use of a uniform electronic prior authorization form when a policy, certificate or contract requires prior authorization for prescription drug benefits. The Department of Insurance may update this form periodically. The form number and most recent revision date are displayed in the top left corner.  \nThis form is made available for use by prescribing providers to initiate a prior authorization request  \nwith a commercial health insurance issuer (\"insurer\") regulated by the Illinois Department of Insurance.  \n\"Prior authorization request\" means a request for pre-approval from an insurer for a specified  \nprescription or quantity of a prescription before the prescription is dispensed.  \n“Prescribing provider\" has the meaning ascribed in Section 364.3 of the Illinois Insurance Code [215 ILCS 5] .  \n“Prescription” has the meaning ascribed in Section 3(e) of the Pharmacy Practice Act [225 ILCS 85] .  \nIf, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of this form, an insurer fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours (if the patient has urgent medication needs), or 72 hours (if the patient has regular medication needs), then the prior authorization request shall be deemed to have been granted [215 ILCS 5/364.3(f)] . The prescribing provider should only provide its direct contact number and initials if requesting an Expedited Review Request.  \nThe provisions of this form do not serve as a replacement for the step therapy and formulary exception requests that may require additional information and forms as provided in Sections 25(a)(3) and 45.1 of the Managed Care Reform and Patient Rights Act [215 ILCS 134]. Nothing in this form shall be construed to alter or nullify any provisions of federal or Illinois law that impose obligations on insurers, prescribing providers, or patients related to responsiveness, adjudication and/or appeals.  \nPrior authorization alone is not a guarantee of benefits or payment. Actual availability of benefits is always subject to other requirements of the health plan, such as limitations and exclusions, payment of premium, and eligibility at the time services are provided. The applicable terms of a patient's plan control the benefits that are available. At the time the claims are submitted, they will be reviewed in accordance with the terms of the plan.  \nPlease refer to the plan's website for additional information that may be necessary for review. Please note that sending this form with insufficient clinical information may result in an extended review period or adverse determination. Insurers may require additional information based on the type of prescription drug being requested that may require follow-up inquiries with the provider.  \nPRESCRIBING PROVIDERS: PLEASE SUBMIT THIS FORM TO THE PATIENT’S HEALTH PLAN ONLY. Please do not send forms to the Department of Insurance.  \nInsurer Contact and Submission Information  \nPlease fax or mail this form to:  \nPrime Therapeutics LLC  \nClinical Review Department  \n2900 Ames Crossing Road  \nEagan, MN 55121  \nPhone: 800-285-9426 Fax: 877-243-6930  \nForm 3643 (06/21) Illinois Department of Insurance Page 2 of 4  \nIllinois Uniform Electronic Prior Authorization Form For Prescription Benefits  \nPROVIDERS SUBMIT THIS FORM TO THE PATIENT’S HEALTH PLAN)  \n Standard Review Request  \nExpedited Review Request: I hereby certify that a standard review period may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function.  \nProvider’s Direct Contact Phone Number ( )- Initials:    \nA) Reason for Request  \nInitial Authorization Req","cbCaiv9xiLgVRoIk","https://ap.wps.com/l/cbCaiv9xiLgVRoIk","pdf",103592,"English","# Insurer contact and submission information\n## Prior authorization overview and legal requirements\n## Prescribing provider submission instructions\n# Standard vs expedited review requests\n## Certification for expedited review\n## Reason for request\n# Patient, provider, and pharmacy sections\n## Patient demographics\n## Prescribing provider information\n## Pharmacy information\n# Requested prescription details and rationale\n## Requested drug information\n## Rationale for prior authorization\n## Failed or contraindicated therapies\n## Other pertinent information\n# Representation","[{\"question\":\"What is prior authorization for prescription benefits under this form?\",\"answer\":\"Prior authorization is a request for pre-approval from an insurer for a specified prescription or quantity before the prescription is dispensed.\"},{\"question\":\"Where should prescribing providers submit this form?\",\"answer\":\"Prescribing providers should submit the form to the patient’s health plan only and not send it to the Illinois Department of Insurance.\"},{\"question\":\"How do insurer response timelines differ for standard vs expedited review?\",\"answer\":\"If the insurer fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours for urgent needs or 72 hours for regular needs, the request is deemed granted.\"}]","Illinois Uniform Electronic Prior Authorization Form For Prescription Benefits - Form 3643 - instructions and submission sections | PDF"]