Bcbs Dispensing Limit Override Physician Fax Form

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DISPENSING LIMIT OVERRIDE
PHYSICIAN FAX FORM
ONLY the prescriber may complete and fax this form.
Incomplete forms will be returned for additional information. The following documentation is required for preauthorization
consideration. For formulary information and to download additional forms, please visit
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 #:
Physician secure email address:
PLEASE ATTACH ANY ADDITIONAL INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST
Patient’s Diagnosis - ICD-9 code plus description:
Medication Requested:
Strength:
Dosing Schedule:
Quantity per Month:
Length of Therapy Requested:
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, quantity and dosing schedule over alternatives (e.g.
contraindications, allergies or history of adverse drug reactions to alternatives, lower dose tried.)
3.
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 or generic products.)
____________________________
Date: ___________
___________________________
Date: __________
____________________________
Date: ___________
___________________________
Date: __________
____________________________
Date: ___________
___________________________
Date: __________
4.
Please list any other medications the patient will use in combination with the requested medication for treatment of this
diagnosis. (Please include strength and quantity per month)
____________________________ Quantity: ________
___________________________
Quantity: ________
____________________________ Quantity: ________
___________________________
Quantity: ________
____________________________ Quantity: ________
___________________________
Quantity: ________
For Narcotic Analgesic Medications
1.
Is the requested medication for management of pain due to active malignancy or the patient is enrolled in a hospice program or
meets hospice criteria for life expectancy of six months or less? ..............................................................
Yes
No
If no, please submit documentation of a formal evaluation including diagnosis and a complete medical history including
previous pharmacological and non-pharmacological therapy.
2.
Is the prescribing physician a specialist, or the patient been evaluated by a specialist, in the area of practice related to the
source of the chronic non-cancer pain? .............................................................................................
Yes
No
Please fax or mail this form to:
CONFIDENTIALITY NOTICE: This communication is intended only for the use
Blue Cross and Blue Shield of Illinois
of the individual entity to which it is addressed, and may contain information
c/o Prime Therapeutics LLC, Clinical Review Department
that is privileged or confidential. If the reader of this message is not the
1305 Corporate Center Drive
intended recipient, you are hereby notified that any dissemination, distribution
Eagan, Minnesota 55121
or copying of this communication is strictly prohibited. If you have received this
communication in error, please notify the sender immediately by telephone at
TOLL FREE
800.858.0723, and return the original message to Blue Cross and Blue Shield
Fax: 877.243.6930
Phone: 800.285.9426
of Illinois c/o Prime Therapeutics via U.S. Mail. Thank you for your cooperation.
6056 IL QL 0312
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
0512
an Independent Licensee of the Blue Cross and Blue Shield Association

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