6002 ILFHP FECR 0114 Blue Cross Community Family Health Plan is provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service
0914 Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association.
FORMULARY EXCEPTION
PHYSICIAN FAX FORM
ONLY 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 preauthorization
consideration. To download additional forms, please visit
www.bcbsilcommunityfamilyhealthplan.com
PATIENT INFORMATION Today’s Date:
Patient Name (First): Last: M: DOB (mm/dd/yyyy):
Patient Address: City, State, Zip Patient Telephone:
INSURANCE INFORMATION
BCBS ID Number: Group Number:
PHYSICIAN/CLINIC INFORMATION
Prescriber Name: Physician NPI#: Specialty: Contact Name:
Clinic Name: Clinic Address:
City, State, Zip: Phone #: Secure Fax #:
PLEASE ATTACH ANY ADDITIONAL INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST
Patient’s Diagnosis – ICD code plus description:
Medication Requested: Strength:
Dosing Schedule: Quantity per Month:
1. Is the patient currently treated with the requested medication? ................................................................. Yes No
If yes, when was treatment with the requested medication started?
2. Please list all reasons for selecting the requested medication over alternatives (e.g. contraindications, allergies or history of
adverse drug reactions to alternatives.)
3. Please list all other medications the patient is currently taking for treatment of this diagnosis.
4. 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.)
Please fax or mail this form to:
Blue Cross and Blue Shield of Illinois
c/o Prime Therapeutics LLC, Clinical Review Department
1305 Corporate Center Drive
Eagan, Minnesota 55121
TOLL FREE
Fax: 877.243.6930 Phone: 800.285.9426
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 Blue Cross and Blue Shield
of Illinois c/o Prime Therapeutics via U.S. Mail. Thank you for your cooperation.
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