Mail to: Prime Therapeutics, LLC
Attention: Determinations
2901 Kinwest Parkway, Bldg. B
Irving, TX 75063
Fax to: (800) 706-5236
Prescribing Physician Request for Medicare Part D Prescription Drug
Coverage Determination Form
This form should be used by a prescribing physician only when requesting a coverage determination
(prior authorization and/or exception) for a Part D prescription drug for a Blue Cross and Blue Shield of
Florida (BCBSF) or Health Options, Inc. Medicare Advantage (BlueMedicare PPO and BlueMedicare
HMO) member. Please complete this form and fax or mail it to the number or address above. You may
also call (800) 727-2227 to request a coverage determination.
This form cannot be used to request barbiturates, benzodiazepines, fertility drugs, drugs for weight loss or
weight gain, drugs for hair growth, over-the-counter drugs, or prescription vitamins (except prenatal
vitamins and fluoride preparations)
Member’s Information:
______________________________
_____________________________________________
Member’s Name
Member’s Date of Birth
______________________________
_____________________________________________
Member’s Medicare Number
Member’s Part D Plan ID Number
____________________________________________________________________________________
Member’s Address
City
State
Zip Code
(____)____________________
Phone
Name of prescription drug requested (if known, include strength, quantity and quantity requested per
month):
Prescribing Physician’s Information:
_______________________________
_____________________________________________
Name
Medical Specialty
____________________________________________________________________________________
Address
City
State
Zip Code
(____)______________________
(____)________________
________________________
Work Phone
Fax
Office Contact Person
900- 450-0107
January 2007
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