Get Esi Medication Prior Authorization Request Form - Unicare

Filling out the ESI Medication Prior Authorization Request Form is essential for obtaining prior authorization for non-preferred medications under UniCare. This guide provides detailed steps to help users complete the form accurately and efficiently online.

Follow the steps to complete your medication prior authorization request.

1. Press the ‘Get Form’ button to access the ESI Medication Prior Authorization Request Form and open it for editing.
2. In the first section, provide the patient's information, including their name, ID number, date of birth, phone number, and email address. Ensure that all fields are accurately filled out to avoid processing delays.
3. Next, fill in the physician's information. This includes the prescribing physician's name, address, phone number, specialty, DEA number, NPI number, and email address. Double-check for accuracy.
4. In the medication section, specify the medication name, its strength, administration directions, and quantity prescribed for 30 days. Make sure to provide as much detail as necessary.
5. Document the diagnosis clearly. This is important for justifying the need for the medication requested.
6. Mark all applicable approval criteria by checking the corresponding boxes. These criteria help support the authorization request and must be chosen carefully.
7. For conditions requiring previous trials, indicate whether the patient has tried the preferred products and provide the names and dates for each.
8. The physician must sign and date the form at the end. This confirms the accuracy and necessity of the provided information.
9. Finally, after completing all sections, save your changes. Options may include downloading, printing, or sharing the completed form for submission.

Complete the ESI Medication Prior Authorization Request Form online today to streamline your medication request process.