Prescriber Fax Form — Drug Prior Authorization Coverage Criteria
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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).
No material clinical or coverage changes in this revision.
Coverage Criteria (Form-driven)
Form-based coverage support criteria
Form queries condition-specific criteria that support coverage when answered affirmatively and with supporting documentation.
see chunk 4 for required fields
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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.
Coding and Key Clinical Thresholds
Submission Instructions and Required Provider Actions
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
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
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
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
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
Initial Therapy Criteria
Breast cancer prevention
Breast cancer prevention therapy prerequisites
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Step Therapy / Prior Use Requirements
| 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
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.
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