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Collects patient and insurance identifiers, prescriber and clinic information, prior authorization rationale, diagnosis (ICD code and date), medication requested (strength, dosing, quantity), treatment history, alternatives tried, combination therapies, and narcotic/opioid or buprenorphine-specific eligibility questions. Includes confidentiality notice and provider contact submission details.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/prior-authorization-prescriber-fax-form-complete-and-fax-by-the-prescriber/288878/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/prior-authorization-prescriber-fax-form-complete-and-fax-by-the-prescriber/288878.png","ImageObject",442,249,{"name":42,"@type":43},"Emma Wilson","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who is allowed to complete and fax this Prior Authorization form?","Question",{"text":63,"@type":64},"Only the prescriber may complete and fax the form.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What types of medication reviews does the form support?",{"text":68,"@type":64},"It is for prospective, concurrent, and retrospective reviews.",{"name":70,"@type":61,"acceptedAnswer":71},"Which documentation is required for prior authorization consideration?",{"text":72,"@type":64},"The form requests documentation including diagnosis (ICD code and date), medication requested (strength, dosing, quantity), treatment history and alternatives tried, and any combination medications, plus specific narcotic/opioid or buprenorphine eligibility information when applicable.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},288878,1790131569,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},3848291630094,"https://eur-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","PRIOR AUTHORIZATION  \nPRESCRIBER 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 prior authorization  consideration. For formulary information and to download additional forms, please visit  \n[https://www.bcbstx.com/provider/medicaid/pharmacy/rx-prior-auth](https://www.bcbstx.com/provider/medicaid/pharmacy/rx-prior-auth)  \nPATIENT AND INSURANCE 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| BCBSTX ID Number: |  |  | Group Number: |  |  |\n\nPRESCRIBER/CLINIC INFORMATION  \n\n| Prescriber Name: | Prescriber 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:   Please provide the date of diagnosis:   |  |\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, please provide start date and current dosing schedule:  \u003Cbr>2. Please list all reasons for selecting the requested medication, quantity and dosing schedule over alternatives (e.g. , contraindications, allergies or history of adverse drug reactions to alternatives , lower dose tried) . \u003Cbr>3. 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. )\u003Cbr>  Date(s) :     Date(s) :  \u003Cbr>  Date(s) :     Date(s) :  \u003Cbr>4. Please list any other medications the patient will use in combination with the requested medication for treatment of this diagnosis. (Please include strength and quantity per month)\u003Cbr>   Quantity:     Quantity:  \u003Cbr>   Quantity:     Quantity:   |  |\n| For Narcotic Analgesic or Opioid Dependence (e.g., Suboxone) Agents\u003Cbr>5. Is the requested medication for management of pain due to active malignancy or the patient is enrolled in\u003Cbr>a hospice program or meets hospice criteria for life expectancy of six months or less?................................ ..  Yes  No If no, please submit documentation of a formal evaluation including diagnosis and a complete medical\u003Cbr>history including previous pharmacological and non-pharmacological therapy.\u003Cbr>6. For buprenorphine requests, does the patient have a pregnancy-related diagnosis in the last 310 days? ....  Yes  No If no, is the patient intolerant to naloxone? ................................ ................................ .............................  Yes  No |  |\n| Prescriber or Authorized Signature:   Date:  \u003Cbr>Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.\u003Cbr>Note: Payment is subject to member eligibility Authorization does not guarantee payment. |  |\n| Please fax or mail this form to:\u003Cbr>Prime Therapeutics LLC, Clinical Review Department 2900 Ames Crossing Road\u003Cbr>Eagan, Minnesota 55121\u003Cbr>TOLL FREE\u003Cbr>Fax: 877.243.6930 Phone: 855.457.0407 | CONFIDENTIALITY NOTIC","cbCaisUu29v0eCLF","https://ap.wps.com/l/cbCaisUu29v0eCLF","pdf",140070,"English","# Patient and Insurance Information\n## Prescriber/Clinic Information\n## Additional Information for Consideration\n## Narcotic Analgesic or Opioid Dependence Questions\n## Signature and Certification\n## Submission and Confidentiality Notice","[{\"question\":\"Who is allowed to complete and fax this Prior Authorization form?\",\"answer\":\"Only the prescriber may complete and fax the form.\"},{\"question\":\"What types of medication reviews does the form support?\",\"answer\":\"It is for prospective, concurrent, and retrospective reviews.\"},{\"question\":\"Which documentation is required for prior authorization consideration?\",\"answer\":\"The form requests documentation including diagnosis (ICD code and date), medication requested (strength, dosing, quantity), treatment history and alternatives tried, and any combination medications, plus specific narcotic/opioid or buprenorphine eligibility information when applicable.\"}]","PRIOR AUTHORIZATION - PRESCRIBER FAX FORM - Complete and fax by the prescriber | PDF",1789634143]