Get 42908843 Form

Filling out the 42908843 form online can streamline the prior authorization process for medication requests. This comprehensive guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information. Fill in the patient name, date of birth, member number, and contact details.
3. Provide the prescriber information, including their name, fax number, and NPI number.
4. Indicate if the request is for expedited or urgent consideration. This may affect processing times.
5. Clearly list the drug name and provide detailed directions for its use.
6. Answer the following questions regarding the patient’s therapy and diagnosis, including whether it is initial or continuing therapy.
7. Speculate the anticipated duration of therapy by selecting one of the predefined options.
8. Answer whether the brand name medication is medically necessary, providing any relevant details.
9. Specify if formulary alternatives are contraindicated and provide details.
10. Answer whether Medicare paid for the pump if the medication is administered via an infusion pump.
11. If applicable, indicate whether the medication will be administered with a nebulizer.
12. Optionally, you can provide additional supporting clinical statements. Include any lab values or treatment failures that may support your request.
13. Finalize by having the prescriber sign and date the form.
14. Once you have completed the form, review all entries for accuracy and ensure no fields are left blank. Save your changes, download, print, or share the completed form as needed.

Start filling out the 42908843 form online today to ensure timely processing of your request.