Get Urxpe Form

Completing the Urxpe Form online is a straightforward process that requires careful attention to details. This guide will walk you through each section of the form to ensure that your submission is accurate and complete.

Follow the steps to fill out the Urxpe Form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information. Include the policy holder's employer, the patient's full name, member ID, date of birth, street address, member phone number, city, state, and zip code.
3. Next, move to the requesting provider information. Fill in the requesting physician or provider’s name, their street address, specialty, city, state, office phone, office fax, office contact name, and the direct line for the office contact, along with the zip code.
4. Indicate whether you would like the response faxed to your office by selecting YES or NO.
5. In the drug information section, enter the requested drug name and strength, quantity per month, directions, diagnosis, length of therapy, and any previous drugs that have been tried along with details such as drug name and strength, directions, and duration or dates used.
6. Provide the clinical rationale for the requested drug tier or quantity limit exception, including any necessary chart notes and supporting labs.
7. Finally, include the requesting provider’s signature and the date. Ensure all information is accurate before proceeding.
8. Once completed, save any changes made to the form. You can then download, print, or share the form as needed.

Complete your Urxpe Form online to ensure a timely and efficient submission.