Get & Xr Prior Authorization Request Form Member ...

Filling out the ® & XR Prior Authorization Request Form online is a structured process that requires careful attention to detail. This guide provides step-by-step instructions on how to navigate each section of the form to ensure all required information is submitted accurately.

Follow the steps to complete the ® & XR Prior Authorization Request Form online.

1. Press the ‘Get Form’ button to retrieve the form and open it in your preferred online editor.
2. Begin filling out the 'Member Information' section. Enter the member's name, date of birth, insurance ID number, and street address, ensuring all fields marked as required are completed.
3. Next, complete the 'Provider Information' section. Input the provider's name, NPI number, office phone number, and address as required.
4. In the 'Medication Information' section, provide the medication name and strength. Indicate whether this is a new medication start by checking 'Yes' or 'No'. Fill in the directions for use and dosage form.
5. Proceed to the 'Clinical Information' section. Select the applicable diagnosis from the options provided, and if 'Other diagnosis' is chosen, ensure to fill in the requested ICD-9/10 code.
6. Detail the medication history by selecting the medications that the patient has been treated with, and indicate if there has been a failure, contraindication, or intolerance to a DPP-4 inhibitor.
7. Provide the quantity requested per day, and state the reason for exceeding plan limitations if needed. Ensure all required comments or additional information are filled in as necessary.
8. Review all entries for accuracy before saving your changes. You can then download, print, or share the completed form as needed.

Complete your ® & XR Prior Authorization Request Form online today!