CVS Caremark's general (global) request for prior authorization or formulary exception for commercial (non-Medicare) prescription benefit plans.
- Completed by
- Prescriber
- Issued by
- CVS Caremark
- Format
- Fillable PDF
- Language
- English
Prime Therapeutics PA/Step Therapy Choice Fax Form
Prime Therapeutics, the pharmacy benefit manager for many Blue Cross and Blue Shield plans, uses this three-page form for prior authorization and step therapy requests for members on its commercial Choice formularies. A prescriber meets it when a prescription rejects for prior authorization or a step requirement. The form handles prospective, concurrent and retrospective reviews and asks why the requested drug was chosen over alternatives.
Who completes it
Only the prescriber may complete the form, including patient and prescriber details, drug information, criteria questions and the attestation signature.
Submitting and payment
- How to submit it
- Fax or mail the form to Prime Therapeutics, or submit an electronic PA through CoverMyMeds, which Prime says gives faster coverage determinations.
Good to know
- Mark Urgent only when the prescriber believes waiting for a standard review could seriously harm the patient's life, health or ability to regain maximum function.
- The criteria ask whether the patient takes the drug now and how it was obtained, such as insurance or samples, and whether it was used in the past 90 days.
- List previously tried and failed drugs with dates, specifying brand-name, generic or over-the-counter products.
- Incomplete forms are returned for more information, and the health plan may audit the medical records behind the answers.
Get the official form
Download the current version from the source each time; forms change without notice.
Prior Authorization/Step Therapy Choice Prescriber Fax Form
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Is there a Blue Cross version of the Prime Therapeutics PA form?
Prime posts client-branded versions of this Choice prior authorization and step therapy form for some health plans, such as HCSC's form on MyPrime, and an Iowa-filed version. Drug-specific criteria and forms are organized per client plan on MyPrime.com and plan portals.
What does the behavioral health section of the Prime form ask?
For behavioral health diagnoses, the form asks for all reasons for choosing the requested drug over alternatives, such as contraindications, risk with change, starting it while in the hospital, allergies or past adverse reactions, or a lower dose already tried. Attach records supporting those reasons.