Get Dispensing Limit Override - Myprimemail

This guide provides clear, detailed instructions on how to accurately complete the DISPENSING LIMIT OVERRIDE form for MyPrimeMail. By following these steps, you can ensure that all necessary information is provided to facilitate the approval process.

Follow the steps to fill out the DISPENSING LIMIT OVERRIDE form online.

1. Click the ‘Get Form’ button to access the DISPENSING LIMIT OVERRIDE form and open it in your preferred editor.
2. Begin by entering today's date in the designated field. Proceed to fill in the patient's first and last name, followed by their complete address, including city, state, and zip code.
3. Input the patient's date of birth in the specified format (mm/dd/yyyy) and their telephone number in the appropriate section.
4. Next, provide the insurance information, including the BCBS ID number and group number to ensure proper processing.
5. Move on to the physician or clinic information. Fill in the prescriber’s name, NPI number, specialty, and clinic name. Include the clinic's address along with the city, state, zip code, and the clinic's phone number.
6. Enter the contact name for follow-up and the secure fax number where the completed form will be sent. If applicable, provide the prescriber’s secure email address.
7. In the section requesting additional information, list the patient's diagnosis with the corresponding ICD-9 code and description. Then, specify the medication requested, along with its strength, dosing schedule, and quantity per month.
8. Detail the length of therapy requested and indicate whether the patient is currently being treated with the requested medication. If yes, include the date treatment commenced.
9. Record the reasons for selecting the requested medication, including any history of contraindications or adverse reactions to alternatives.
10. List all medications the patient has previously tried and their outcomes. Be sure to mention if they were brand-name or generic.
11. Under the narcotic analgesic medications section, answer if the medication is for pain management related to malignancy or hospice criteria, and if the prescribing physician or specialist evaluated the patient.
12. Once the form is entirely completed, review all entered information for accuracy. Save your changes, and once you're satisfied, you may download, print, or share the form as needed.

Complete your DISPENSING LIMIT OVERRIDE form online today for efficient processing.