Get Drug Prior Authorization Fax Form - Excellus Bcbs

This guide provides clear instructions on how to accurately complete the Drug Prior Authorization FAX Form for Excellus BCBS. By following these steps, you can ensure that all necessary information is provided for the authorization process.

Follow the steps to fill out the Drug Prior Authorization FAX Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the Patient/Physician information section. Fill in the patient's name, phone number, and medication shipping address clearly.
3. List any patient allergies in the designated field, if applicable, and provide the FLRx Patient ID number.
4. Fill out the prescribing physician's details, including name, phone number, and DEA number.
5. Indicate the patient's birthdate, specialty of the prescribing physician, and their fax number.
6. In the medical necessity section, check the applicable drug and specify the strength, directions, and quantity of medication requested.
7. Answer the questions regarding the patient's condition and any prior treatments that have been attempted.
8. If the patient has Ankylosing spondylitis, confirm if they have tried and failed two different NSAIDs and list them in the provided space.
9. Provide any additional comments or justifications in the comments section.
10. Finally, ensure the prescriber signs and dates the form to certify the accuracy of the information provided.
11. Once all fields are completed, save changes to the document, and then you can download, print, or share the form as needed.

Complete your forms online today to streamline the authorization process.