CurrentFlorida BluePolicy N/A

Prescriber Prior Authorization Request Form — Medication Coverage Determination

This document is a prescriber-completed prior authorization form used to request coverage for a specific medication for Florida Blue members; it governs what documentation must accompany a drug coverage request and who must complete it.

Policy Summary

PayerFlorida Blue

PolicyPrescriber Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax a completed prescriber-signed prior authorization form with required documentation to Prime Therapeutics at 877.480.8130 for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1required prescriber signature/source (only prescriber may complete form)

6+explicit clinical/data items requested

877.480.8130fax number for submission

888.271.3183phone number for inquiries

Coverage and Medical Necessity Requirements

Information required for medical necessity review

Coverage determination will be based on review of submitted documentation demonstrating medical necessity, including:

Submission completeness: Form fully completed and signed by the prescriber with patient, insurance, and prescriber/clinic information provided

Incomplete forms will be returned

Diagnosis documentation: Patient's diagnosis provided with ICD-9 code and description

Medication request details: Medication name, strength, dosing schedule, and quantity per month provided

Attach any additional supporting information

Policy Summary

PayerFlorida Blue

PolicyPrescriber Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax a completed prescriber-signed prior authorization form with required documentation to Prime Therapeutics at 877.480.8130 for review.

SourceLink

On This Page

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Therapeutic rationale:

List all reasons for selecting the requested medication, including contraindications to alternatives or prior lower-dose trials

Prior therapy: List of prior medications tried and failed for this diagnosis, specifying brand-name or generic where applicable

Supports step-therapy assessment

Concomitant medications: List any other medications the patient will use in combination with the requested medication for this diagnosis

Dose justification if exceeding FDA labeling: If prescribed dose exceeds the maximum recommended in FDA-approved labeling, provide documentation supporting safety and efficacy (e.g., practice guidelines or peer-reviewed clinical trials)

Medication-overuse headache assessment: For headache indications, confirm whether the patient has been evaluated for chronic daily headache caused by medication overuse (Yes/No)

LMWH-specific prior therapy: If the requested medication is a low molecular weight heparin, document whether the patient has tried and failed warfarin (Coumadin); if not, provide explanation

Applicable only to LMWH requests

No additional explicit coverage criteria or exclusions are listed on the form; the form collects information to support a medical-necessity review rather than specifying approval rules.

A completed, prescriber-signed form with all required fields and supporting documentation must be submitted; incomplete forms will be returned for additional information and missing documentation may delay or result in denial of the request.

Diagnosis and Billing Codes

Requested diagnosis codeICD-10

ICD-9

Patient's Diagnosis ICD-9 code plus description

What the Prescriber Must Submit

Prior Authorization

Submission Requirement

The prescriber (ONLY the prescriber) must complete and sign the prior authorization form. Incomplete forms will be returned for additional information and may delay or result in denial of the request. For formulary information, visit the Florida Blue website.

Form must be prescriber-signed.
Incomplete submissions will be returned or may be denied.
Formulary information: Florida Blue website.

Documentation Required

Required Documentation and Form Fields

Provide complete patient, insurance, and prescriber/clinic demographics and contact details on the form. Attach any additional supporting documentation as noted below.

Patient demographics: name, DOB, address, telephone.
Insurance: ID number, group number.
Prescriber/clinic: prescriber name, specialty, Physician NPI#, clinic name, contact name, clinic address (city, state, ZIP), phone number, secure fax number.

Step Therapy

Prior Therapy Documentation

Document prior medication history and reasons for selecting the requested therapy. List all prior therapies tried and failed, indicate brand/generic when applicable, and provide details supporting step-therapy or therapeutic failure.

List all medications previously tried and failed for this diagnosis; specify brand-name or generic when applicable.
State reasons for selecting the requested medication, strength, dosing schedule and quantity over alternatives (e.g., contraindications, intolerance, insufficient response).
List concurrent medications that will be used in combination with the requested therapy.
If dose exceeds FDA‑approved maximum, provide supporting evidence for safety and efficacy (practice guidelines, clinical trials, peer-reviewed literature).
For headache indications, document evaluation for chronic daily headache due to medication overuse (Yes/No).
If requesting a low molecular weight heparin, indicate whether warfarin (Coumadin) was tried and failed; if not, provide reason.

Documentation Required

Additional Attachments and Submission

Attach any additional information that should be considered with this request (e.g., medical records, laboratory data, office notes). Fax or mail the completed and signed form to Prime Therapeutics using the contact information below.

Attach supporting documentation (office notes, diagnostics, labs).
Fax completed form to Prime Therapeutics: 877-480-8130.
Mail to: Prime Therapeutics LLC Clinical Review Department, 1305 Corporate Center Drive, Eagan, Minnesota 55121.
For assistance call: 888-271-3183.

Denial Risk

Incomplete Submission Consequences

Incomplete or missing information will result in the form being returned for additional information and may delay or cause denial of the authorization.

Missing required fields or signatures may result in return, delay, or denial.

Clinical Rationale

The form requests a clinical justification for the requested medication, including the patient’s diagnosis (ICD-9 code and description), reasons for selecting the requested medication over alternatives (for example, contraindications or prior intolerance), a detailed list of prior medications tried and failed (specifying brand or generic), concomitant medications, documentation if the prescribed dose exceeds FDA-approved labeling, and an evaluation for medication-overuse headache when applicable.

Key Definitions and Evaluations

Medication overuse headache — evaluation definition and related items

DefinitionMedication overuse headache evaluation: confirmation of whether the patient has been evaluated for chronic daily headache caused by medication overuse (Yes/No).

When requiredRequested for headache indications as part of clinical justification when submitting prior authorization for a headache-related medication.

Documentation to provideIndicate whether patient was evaluated for medication‑overuse headache and include supporting clinical notes if evaluation was positive or relevant treatment was attempted.

Form field locationQuestion 5 on the prior authorization form asks: 'Has the patient been evaluated for chronic daily headache caused by medication overuse? Yes / No.'

Impact on reviewResponses inform clinical review of medical necessity and may affect approval if medication overuse is the primary cause of chronic headache rather than the requested therapy needing coverage.