Get Prior Authorization Request Form For Non-specialty Drugs - Ambetter

Completing the Prior Authorization Request Form For Non-Specialty Drugs - Ambetter is essential for obtaining necessary medications. This guide provides clear, step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in the editing tool.
2. Begin with Section I: Provider Information. Fill in the prescriber name, office contact name, fax number, phone number, and the date. Complete the group name and group number along with the identification number for the member.
3. Proceed to Section II: Member Information. Enter the member name and date of birth to ensure identification is correct. This section also requires noting any medication allergies.
4. Move to Section III: Drug Information. Specify the drug name and strength, dosage form, dosage interval, and quantity per day. Clearly outline the diagnosis relevant to this request and the expected length of therapy.
5. Answer the medication history questions. Indicate whether the member is currently treated with this medication, answer related follow-up questions regarding previous approvals, and detail any changes in dosage or strength.
6. If applicable, provide previous treatment details in Section D, including drug names, dates of therapy, and reasons for any discontinuation.
7. In Section IV, provide the rationale for the request and any pertinent clinical information that supports medical necessity. This information is critical for the review process.
8. Finally, ensure the provider signature is completed along with the date to authorize the request. Review the entire form for completeness before submission.
9. Save your changes, download the completed form, print, or share it as needed for submission.

Start your prior authorization process by completing the document online today.