Get 8004373803

This guide provides comprehensive instructions on how to fill out the 8004373803 form for prior authorization requests with Blue Cross Complete. Follow the steps carefully to ensure that all necessary information is included for a successful submission.

Follow the steps to complete your prior authorization request effectively.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editing program.
2. Enter the patient and physician information. Provide the patient’s name, date of birth, member ID number, and the physician's name, NPI/DEA number, phone number, and fax number.
3. Fill in the medication drug name requested, along with the dosage instructions or 'Sig'. Clearly state why the medication is required, providing any necessary details to support the request.
4. List previously used formulary medications related to the patient's diagnosis. Include the strength, duration of use, and detailed information on each medication's regimen and the reasons for discontinuation.
5. Indicate if the patient has experienced therapeutic failure with all available formulary drugs within the same therapeutic class, or exhibited intolerance to them. Ensure that all requested information is completed accurately.
6. Review the form for accuracy and completeness. Make sure to include documentation of any previous medications as required for consideration of coverage.
7. Once all fields are filled out and checked for accuracy, save the completed form. You may download, print, or share the form as needed. Ensure to fax the form and any supporting documentation to 1-877-442-3778.

Complete your prior authorization request online today to ensure timely processing.