Get Part B Drug Prior Authorization

Filling out the PART B Drug Prior Authorization form online is a crucial step in ensuring that necessary medications are accessed in a timely manner. This guide provides clear, step-by-step instructions to assist users in completing the form correctly.

Follow the steps to successfully complete the authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering today's date in the appropriate field. This date is essential for tracking the request timeline.
3. Indicate the type of review by checking either the standard review (14 days) or the expedited review (72 hours) box. If you select expedited, certify that a standard review may jeopardize the member's health or ability to recover.
4. Fill in the patient information section, including the patient's name, date of birth, address, and Essence ID number. Ensure that all details are accurate.
5. Provide the prescriber information, including the prescriber's name, office contact, and contact details. Include drug allergies if applicable.
6. In the drug dispensing and administration section, specify who will be furnishing the drug and the facility where it will be administered, if applicable.
7. Input the medication name (e.g., , , etc.), dosage, route, frequency, and whether this is a new start or a continuation of treatment.
8. Select the corresponding diagnosis from the options provided and input any additional relevant medical information.
9. Report the required medical information, including lab results and dates, ensuring they meet the requested criteria.
10. Complete the symptoms related to anemia section, detailing any issues the patient is experiencing.
11. Provide the prescriber’s signature and date to finalize the form, confirming all information is complete and accurate.
12. After completing the form, review all entries for accuracy, then save changes, and prepare to submit your authorization request via fax.

Complete the PART B Drug Prior Authorization form online today to ensure timely access to necessary treatments.