Get Prior Authorization Form For Cox-2 - Unison Health Plan Home

This guide provides step-by-step instructions on how to effectively complete the Prior Authorization Form For COX-2 - Unison Health Plan Home online. By following these instructions, you can ensure that all necessary information is accurately submitted to facilitate a smooth approval process.

Follow the steps to complete the form successfully

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section, which includes the patient's name, date of birth, and member ID number. Ensure all fields are completed accurately.
3. Indicate the duration of the requested medication by filling out the duration field. This should reflect how long the medication is needed.
4. In the drug requested section, clearly state the name of the COX-2 inhibitor that is being requested, followed by the dosage and administration details in the dosage and Sig field.
5. Provide the fax number to which the request should be sent, stating the specific attention required for the request.
6. Complete the physician's information, including the name, phone number, fax number, and address. The NPI number must also be filled out as it is required.
7. Specify the patient diagnosis by checking the appropriate box (osteoarthritis, rheumatoid arthritis, or other) and including the ICD-9 code if necessary.
8. Answer the gastrointestinal related diagnosis questions and provide the necessary details based on the patient's medical history.
9. Detail any other medications the patient is taking, including chronic corticosteroids and anticoagulants, if applicable.
10. If the patient has previously used other NSAIDs, please list them along with the dosages and reasons for discontinuation. If no NSAIDs have been tried, provide a reason.
11. Include any additional information relevant to the request to support the physician's authorization.
12. Review the completed form for accuracy, then save the changes, and download or print a copy for your records before submitting.

Complete your Prior Authorization Form online to ensure timely processing of your request.