[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283755-105":53,"doc-detail-283755-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","physician-fax-form-prime-therapeutics-prior-authorization-form","Physician Fax Form - Prime Therapeutics Prior Authorization Form","","Physician Fax Form for Prime Therapeutics requests prior authorization reviews for prospective, concurrent, and retrospective cases. The form requires completion and faxing by the prescriber, with incomplete submissions returned for missing details. It collects patient demographics, insurance identifiers, and prescriber/clinic information, and requests supporting documentation for review consideration. It also captures diagnosis with ICD code, medication details (strength, dosing, monthly quantity), current treatment status, rationale versus alternatives, current concomitant medications, and prior therapies failed.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/physician-fax-form-prime-therapeutics-prior-authorization-form/283755/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/physician-fax-form-prime-therapeutics-prior-authorization-form/283755.png","ImageObject",442,249,{"name":88,"@type":89},"Connor ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":35},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who is allowed to complete and fax the form?","Question",{"text":108,"@type":109},"Only the prescriber may complete and fax this prior authorization form.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What types of reviews does the form support?",{"text":113,"@type":109},"The form is used for prospective, concurrent, and retrospective reviews.",{"name":115,"@type":106,"acceptedAnswer":116},"Which clinical information must be included for preauthorization consideration?",{"text":117,"@type":109},"The form requests diagnosis with ICD code and description, medication requested (including strength), dosing schedule, quantity per month, current treatment status, reasons for selecting the medication, current medications for the diagnosis, and prior medications tried and failed.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283755,1791392338,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":35,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},687207022233,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","FORMULARY EXCEPTION  \nPHYSICIAN FAX FORM  \nONLY the prescriber may complete and fax this form. This form is for prospective, concurrent, and retrospective reviews.  Incomplete forms will be returned for additional information. The following documentation is required for preauthorization consideration. To download additional forms, please visit www. bcbsilcommunityfamilyhealthplan.com  \nPATIENT INFORMATION Today’s Date:  \n\n| Patient Name (First): | Last: | M: | DOB (mm/dd/yyyy): |\n| --- | --- | --- | --- |\n| Patient Address: | City, State, Zip | Patient Telephone: |  |\n\nINSURANCE INFORMATION  \n\n| BCBS ID Number: | Group Number: |\n| --- | --- |\n\nPHYSICIAN/CLINIC INFORMATION  \n\n| Prescriber Name: | Physician NPI\\#: |  | Specialty: |  | Contact Name: |\n| --- | --- | --- | --- | --- | --- |\n| Clinic Name: |  | Clinic Address: |  |  |  |\n| City, State, Zip: |  | Phone \\#: |  | Secure Fax \\#: |  |\n\nPLEASE ATTACH ANY ADDITIONAL INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST  \n\n| Patient’s Diagnosis – ICD code plus description: |  |\n| --- | --- |\n| Medication Requested: Strength: |  |\n| Dosing Schedule: Quantity per Month: |  |\n| 1. Is the patient currently treated with the requested medication? ................................................................ .  Yes  No If yes, when was treatment with the requested medication started?  \u003Cbr>2. Please list all reasons for selecting the requested medication over alternatives (e.g. contraindications, allergies or history of adverse drug reactions to alternatives. )  \u003Cbr>3. Please list all other medications the patient is currently taking for treatment of this diagnosis.  \u003Cbr>4. Please list all 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. )   |  |\n| Please fax or mail this form to:\u003Cbr>Blue Cross and Blue Shield of Illinois\u003Cbr>c/o Prime Therapeutics LLC, Clinical Review Department 1305 Corporate Center Drive\u003Cbr>Eagan, Minnesota 55121\u003Cbr>TOLL FREE  Fax: 877.243.6930 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. |\n\nMade Fillable by eForms","cbCaif8uhA7R4ApZ","https://ap.wps.com/l/cbCaif8uhA7R4ApZ","pdf",68560,"English","# Patient information\n## Insurance information\n## Physician/clinic information\n## Required clinical details\n## Submission instructions","[{\"question\":\"Who is allowed to complete and fax the form?\",\"answer\":\"Only the prescriber may complete and fax this prior authorization form.\"},{\"question\":\"What types of reviews does the form support?\",\"answer\":\"The form is used for prospective, concurrent, and retrospective reviews.\"},{\"question\":\"Which clinical information must be included for preauthorization consideration?\",\"answer\":\"The form requests diagnosis with ICD code and description, medication requested (including strength), dosing schedule, quantity per month, current treatment status, reasons for selecting the medication, current medications for the diagnosis, and prior medications tried and failed.\"}]","Physician Fax Form - Prime Therapeutics Prior Authorization Form | PDF",1789618773]