FLORIDA BLUE
MISCELLANEOUS DRUG
PRIOR AUTHORIZATION FORM
ONLY the prescriber may complete this form. This form is for prospective, concurrent, and retrospective reviews.
PLEASE NOTE: Incomplete forms will be returned for additional information. To ensure you are submitting this form correctly, you can
complete and submit it directly to us online at www.covermymeds.com
For formulary information, please visit the Florida Blue website at http://www.floridablue.com
PATIENT INFORMATION
Patient First Name:
Patient Last Name:
Patient Street Address:
City, State
MI:
ZIP
DOB (mm/dd/yyyy):
AGE:
Patient Phone:
INSURANCE INFORMATION
Patient ID Number:
Group Number:
PHYSICIAN/CLINIC INFORMATION
Prescriber First Name:
Prescriber Last Name:
NPI:
Specialty:
Clinic Name:
Contact Name:
Phone:
Secure Fax:
Clinic Street Address:
City, State
ZIP
MEDICAL INFORMATION. PLEASE ATTACH ADDITIONAL INFORMATION AS NEEDED.
Patient Diagnosis with ICD-9 Code:
ICD-10 Code:
Medication and Strength Requested:
Dosing Schedule:
Quantity per Month:
Is the patient currently treated with the requested medication?.............................................................................. ☐ Yes
☐ No
If yes: When was treatment with the requested medication started? ______________________________
Please list all reasons for selecting the requested medication over alternatives (e.g., contraindications, allergies, history of adverse
drug reactions to alternatives.)
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
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, generic, or over-the-counter products.)
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Please list any other medications the patient will use in combination with the requested medication for treatment of this diagnosis.
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Please fax or mail this form to:
Prime Therapeutics LLC
Medical Drug Review Department
1305 Corporate Center Drive
Eagan, Minnesota 55121
TOLL FREE
FAX: 855.729.7216
PHONE: 866.260.0452
Misc_FL_CS_PAQL_MDRQ_AR0315
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 Prime Therapeutics via U.S. Mail. Thank you for
your cooperation.
© PRIME THERAPEUTICS LLC
Florida Blue and Florida Blue HMO Prescription Drug Benefits are administered by Prime Therapeutics, our pharmacy benefit manager (PBM).
Patient First Name:
Patient Last Name:
MI:
DOB (mm/dd/yyyy):
Prescription Section
Will you, acting as the patient’s agent, or will your patient be using Prime Therapeutics Specialty Pharmacy to
process this prescription and fill the order?.................................................................................................................. ☐ Yes
☐ No
If yes: Please use the section below to complete the prescription:
If no: Please refer back to the Florida Blue website for additional information and the correct forms to submit for appropriate review
(http://www.bcbsfl.com/DocumentLibrary/Providers/Content/Rx_PriorAuthorization.pdf).
Medication Name, Form, Strength, Dose: __________________________________________________________________
Directions: __________________________________________________________________________________________
Frequency:
Quantity: _________________________ Refills: NR 1 2 3 4 5 _____
☐ Check this box if you would like the associated supplies dispensed along with injectable medications.
PRESCRIBER SIGNATURE: Prescriber signature is required to validate prescriptions.
_________________________________________________
☐ Dispense as written
Date
Please fax or mail this form to:
Prime Therapeutics LLC
Medical Drug Review Department
1305 Corporate Center Drive
Eagan, Minnesota 55121
TOLL FREE
FAX: 855.729.7216 PHONE: 866.260.0452
Misc_FL_CS_PAQL_MDRQ_AR0315
___________________________________________
☐ Substitution permitted
Date
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
866.469.5660, and return the original message to Prime Therapeutics via U.S.
Mail. Thank you for your cooperation.
© PRIME THERAPEUTICS LLC
Florida Blue and Florida Blue HMO Prescription Drug Benefits are administered by Prime Therapeutics, our pharmacy benefit manager (PBM).