Get 18662408123

Completing the 18662408123 form efficiently is crucial for managing prescription drug requests. This guide provides clear, step-by-step instructions to help you fill out the form online with confidence.

Follow the steps to successfully complete your medication request form.

1. Press the ‘Get Form’ button to access the medication request form and open it in your designated editor.
2. Begin by filling in the patient information section. This includes the subscriber ID number, group number, patient name, address, date of birth, and their contact number. Ensure that you provide accurate details to prevent any delays.
3. Next, move on to the clinical/medication information section. Here, you will need to specify the drug name, strength or dose, diagnosis, and details regarding any recent transplants, including the type and date. Indicate the requested quantity per month.
4. If applicable, list any alternatives that the patient has tried or used, including the drug names and strengths. Documentation of therapy failures should also be included in this section.
5. In the physician information section, please provide the physician's name, NPI or tax ID number, address, contact number, and their signature along with the date. This information is crucial for mailing notifications.
6. Select the request type based on your needs. Options may include tiering exception, non-formulary, standard request, or prior authorization.
7. Once all relevant fields have been filled out, review the form to ensure that all information is accurate and complete. After a final check, you may save your changes, download the form for your records, or print it out for faxing.
8. Finally, fax the completed form to 1-866-240-8123 or mail it to the specified address for submission.

Take the next step in managing prescription requests by completing your forms online today.