Get Primemail Prior Authorization Form

Filling out the Primemail Prior Authorization Form online can streamline the process of requesting medication approval. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete your form accurately.

1. Click the ‘Get Form’ button to access the Primemail Prior Authorization Form and open it in your preferred online editor.
2. Begin by providing your contact information in the 'Completed by' section. Include a direct phone number for any follow-up questions regarding the authorization request.
3. In the 'Prescriber Information' section, fill in the prescriber's last name, first name, DEA/NPI number, specialty, phone, and fax. Ensure that all information is accurate to avoid delays.
4. Next, enter the member's information including their last name, first name, member ID number, and date of birth (DOB). Confirm that the member ID is accurate as it is essential for processing.
5. Proceed to the 'Medication Information' section. Indicate the drug name and strength, specify the quantity and dosing, state the diagnosis, and the duration of treatment required.
6. Select the type of medication request by checking either 'NEW' for a new prescription or 'RENEWAL' for an ongoing treatment. If renewing, provide the original prescription date.
7. Address the Prior Authorization Criteria by answering all questions regarding prior medication trials. It is crucial to document any drugs taken, the dates of trials, and reasons for failures in the provided spaces.
8. Include any additional information pertinent to the authorization request in the designated section to provide context or justification for the medication.
9. Finally, sign the form in the 'Prescriber or Authorized Signature' section and date it. This attests that the information provided is accurate as of the date signed.
10. Once all sections are completed, you can save changes, download the form, print it for records, or share it as required to submit your request.

Complete your Primemail Prior Authorization Form online today for a smooth submission process.