Get Envision Rx Step Therapy Form

This guide will provide you with comprehensive and user-friendly instructions on completing the Envision Rx Step Therapy Form online. By following these steps, you will ensure that all necessary information is accurately submitted for review.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Envision Rx Step Therapy Form and open it for editing.
2. Carefully enter the patient name in the designated field, ensuring that it is spelled correctly.
3. Fill in the member number, along with the patient's date of birth, and provide the necessary contact information, such as phone number and fax number.
4. Input the prescriber’s name and contact details, including office contact and state license ID.
5. Indicate the drug name and provide clear directions for use in the corresponding sections.
6. If applicable, select the diagnosis for which the medication is prescribed—options include post-herpetic neuralgia, diabetic peripheral neuropathy, or other. If 'other' is selected, specify in the subsequent question.
7. Answer the question regarding whether the patient has previously tried and failed the BRAND patches by selecting 'Yes' or 'No'.
8. In the additional comments section, provide any supporting clinical information, such as notes or relevant medical history that may assist with the approval.
9. Ensure that the prescriber signs and dates the form, confirming the accuracy of the information provided.
10. Once all required fields are completed, proceed to save the changes made to the form. You can select options to download, print, or share the finalized form as needed.

Take action now by completing your documents online!