Get Cns Stimulants Prior Authorization Request Form Page 1 Of 2

Filing a prior authorization request is an essential step in ensuring access to necessary medications. This guide provides clear instructions on how to complete the CNS stimulants prior authorization request form online, ensuring all necessary information is submitted correctly.

Follow the steps to effectively complete your prior authorization request

1. Click ‘Get Form’ button to obtain the form and open it for filling out.
2. In the member information section, carefully enter the member's name, date of birth, and insurance ID number. Make sure all fields are filled out as this information is required for processing.
3. Enter the provider information including provider name, office phone, NPI number, and office address. Ensure accuracy to avoid any delays in processing.
4. In the medication information section, specify the medication name and strength. Check the appropriate boxes if you are requesting a brand name or if this request is for continuation of therapy.
5. Under clinical information, select the appropriate diagnosis from the provided options. If your diagnosis is not listed, specify it under 'Other diagnosis' and include the corresponding ICD-9/10 codes.
6. For narcolepsy, indicate if a sleep study has been performed and results submitted. Answer yes or no accordingly.
7. For binge eating disorder, answer the series of questions regarding the patient’s experiences and confirm diagnosis duration.
8. If this is a reauthorization request, provide documentation of the patient’s positive clinical response to therapy.
9. List any medications that the patient has failed, has a contraindication to, or is intolerant to, by checking the appropriate boxes.
10. If requesting a quantity limit, specify the quantity requested per day and provide a reason for exceeding plan limitations.
11. Review all entries for accuracy. Ensure all required sections are completed before proceeding to save changes, download, print, or share the completed form.

Complete the CNS stimulants prior authorization request form online to facilitate timely access to necessary medications.