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BlueRx Physician Drug Authorization Form Alseib 2014-2023
Licensee of the Blue Cross and Blue Shield Association. Prime Therapeutics an independent company manages pharmacy benefits for BlueRx PDP members on behalf of Blue Cross and Blue Shield of Alabama. You may mail the signed and completed form to Prime Therapeutics LLC 1305 Corporate Center Drive Eagan Minnesota 55121. GENERAL INFORMATION Request Type please check one Prior Authorization Step Therapy Exception Request Non-formulary Drug Request for Tiering Exception Request for Quantity Limit...
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