CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Prescriber Fax Form — Drug Prior Authorization Coverage Criteria

Form used by prescribers to request prospective, concurrent, or retrospective prior authorization and to provide required documentation for medication requests affecting Blue Cross Blue Shield - Rhode Island members (via Prime Therapeutics).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPrescriber Fax Form — Drug Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionOnly the prescriber may complete the form and submit required documentation (including diagnosis, medication, dosing, and quantity) via fax to 855.212.8110 or by mail/phone as provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1fax number provided for submission

TOLL FREEphone contact provided

multipledistinct medication-specific question blocks

requiredrequired documentation (incomplete returns)

Coverage Criteria (Form-driven)

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Form-based coverage support criteria

Form queries condition-specific criteria that support coverage when answered affirmatively and with supporting documentation.

All Requests: Prescriber must indicate whether patient is currently treated with the requested medication and list reasons the request is medically necessary (e.g., contraindications, allergies, adverse reactions to alternatives, or prior lower dose tried).

see chunk 4 for required fields

Aspirin Therapy: For aspirin use: confirm pregnancy status and timing (use after 12 weeks gestation for preeclampsia risk), whether the medication is for primary prevention of CVD with a 10% or greater 10-year CVD risk, for primary prevention of colorectal cancer (CRC), willingness/ability to take low-dose aspirin daily for at least 10 years, and assessment of increased bleeding risk.10% CVD risk

see chunk 5

Breast Cancer Prevention Therapy: For primary prevention of breast cancer: indicate whether patient has used a generic equivalent prerequisite (e.g., generic raloxifene for Evista; generic tamoxifen for Soltamox). If no prior use, document intolerance, an FDA‑labeled contraindication, or hypersensitivity to the generic equivalent and provide explanation. Also document patient's sex and rationale if not female.

see chunk 7

HIV PrEP: Patient must be at high risk for HIV infection and have a recent negative HIV test. Indicate whether the requested medication is TDF/FTC combination or TDF single‑ingredient; if not, document that TDF/FTC or TDF is contraindicated, likely less effective, or would cause harm, with explanation.

see chunk 10

Statin Therapy: For primary prevention of CVD with statin therapy: indicate presence of CVD risk factors (dyslipidemia, diabetes, hypertension, smoking) and whether the patient's calculated 10‑year ASCVD risk is 10% or greater per ACC/AHA calculator.10% ASCVD risk

see chunk 13

Tobacco Cessation: For tobacco cessation therapies: confirm patient is a non‑pregnant adult, document if patient received more than a 180‑day supply of the requested medication type in the past 365 days; if so, indicate current treatment status and whether success is anticipated or additional explanation if extending therapy is needed.>180 days supply

see chunk 14

Vaccine Therapy: Indicate that the requested vaccine will be used per ACIP/CDC recommendations.

see chunk 15

The form is structured to elicit condition‑specific eligibility that, when not met, implies exclusion of coverage. For example, aspirin for primary CVD prevention requires documentation that the patient has a 10% or greater 10‑year CVD risk before the request is supported, and breast cancer prevention agents require prior use of a listed generic equivalent (e.g., generic raloxifene for Evista or generic tamoxifen for Soltamox) or documented intolerance/contraindication to that generic. Requests that do not meet these prerequisite use or patient characteristic checks are not supported by the form and therefore are not eligible for approval based on the form responses.

The form does not contain explicit language declaring therapies not medically necessary, but it requires the prescriber to state whether the patient is currently treated with the requested medication and to list all reasons the medication, dosing, and quantity are medically necessary. Incomplete or absent clinical justification and missing required fields will prevent approval because the form relies on those responses to support authorization decisions.

Submission Instructions and Required Provider Actions

Prior Authorization

Submission method

Prior authorization requests (prospective, concurrent, or retrospective) must be submitted using the prescriber fax form. Only the prescriber may complete this form. To submit electronically, use covermymeds.com; for formulary information visit www.myprime.com.

Form is required for prospective, concurrent, and retrospective reviews
Only the prescriber may complete and sign the form
Electronic submission available via covermymeds.com; formulary info at www.myprime.com

Documentation Required

Generic prerequisite check

For breast cancer prevention therapy requests, the form includes questions about whether the medication is being used for primary prevention and whether a generic equivalent prerequisite was tried. If a generic equivalent was not used, documentation of intolerance, FDA-labeled contraindication, or hypersensitivity to the generic must be provided and explained on the form.

Question asks if medication is for primary prevention of breast cancer
Ask whether a generic equivalent (e.g., generic raloxifene for Evista; generic tamoxifen for Soltamox) was used
If generic not used, must document intolerance, FDA contraindication, or hypersensitivity and provide explanation

Documentation Required

Required submitter and fields

The following fields and documentation are required; incomplete submissions will be returned for additional information. Include the patient's diagnosis (ICD code + description), medication requested (name, strength, dosing schedule, quantity per month), patient demographic details (name, DOB), and any supporting documentation or additional information to be considered.

Required fields: Patient name, DOB, Diagnosis (ICD code + description)
Medication details: name, strength, dosing schedule, quantity per month
Attach any additional supporting documentation; incomplete forms will be returned

Denial Risk

Incomplete submission risk

Incomplete or missing information will result in the form being returned and may delay review or denial of the request. Ensure all required fields and supporting documentation are included before submission.

Incomplete forms will be returned for additional information
Missing documentation may delay review or result in denial

Note

Where to send the form

Please fax or mail completed forms to Prime Therapeutics Clinical Review Department. Fax submissions to 855.212.8110 or mail to Prime Therapeutics LLC, Clinical Review Department, 2900 Ames Crossing Road, Eagan, MN 55121. For questions call 855.457.0759. Confidentiality notice applies.

Fax: 855.212.8110
Phone: 855.457.0759
Mail: Prime Therapeutics LLC Clinical Review Department, 2900 Ames Crossing Road, Eagan, MN 55121

Step	Requirement	If requirement not met
1	Prior use of a generic equivalent prerequisite (e.g., generic raloxifene for Evista; generic tamoxifen for Soltamox) is documented in the patient's medication history.	Approval may be supported; provide documentation of prior generic use as shown on medication history.
1	If prior use of the generic equivalent prerequisite is not documented, the prescriber must indicate whether the patient has a documented intolerance, FDA‑labeled contraindication, or hypersensitivity to the generic equivalent.	Provide documentation of intolerance, FDA‑labeled contraindication, or hypersensitivity; without such documentation the request may not meet criteria.

Definitions and Background

10-year CVD risk threshold — primary prevention

Primary prevention threshold10% or greater 10-year CVD (ASCVD) risk

Applied toAspirin and statin primary prevention sections on the form

Risk calculator referencePer American College of Cardiology/American Heart Association (ASCVD) 10-year risk calculator for statins

HIV PrEP — candidate requirements and medication specifics

Candidate requirementsPatient must be at high risk of HIV infection and have recently tested negative for HIV

Preferred medications queried on formTenofovir disoproxil fumarate and emtricitabine (TDF/FTC) combination or tenofovir disoproxil fumarate (TDF) single ingredient

Alternatives justificationIf requested medication is not TDF/FTC or TDF, form asks whether TDF-containing options are contraindicated, likely less effective, or would cause harm

This prescriber form captures the clinical rationale across multiple medication classes to support prior authorization decisions. Sections include queries for aspirin therapy (pregnancy/preeclampsia use after 12 weeks, primary prevention of CVD with a 10% or greater 10‑year CVD risk, colorectal cancer prevention, bleeding risk, and planned duration), breast cancer prevention agents (use for primary prevention, prior generic equivalent use or documented intolerance/contraindication, and patient sex), and a general All Requests section that asks whether the patient is currently treated with the requested medication and for a statement of medical necessity (diagnosis, contraindications, allergies, prior lower dose tried). These condition‑specific questions are intended to document eligibility and contraindications needed to justify coverage.

OpenPayer

Prescriber Fax Form — Drug Prior Authorization Coverage Criteria

Coverage Criteria (Form-driven)

Coding and Key Clinical Thresholds

Submission Instructions and Required Provider Actions

Initial Therapy Criteria

Step Therapy / Prior Use Requirements

Definitions and Background