Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate the purpose of your request by checking either 'Initial Request' or 'Continuation/Renewal Request'. If applicable, check the box for 'Expedited Review/Urgent Request' to attest the request meets the criteria for urgent reviews.
3. In section A, provide the health plan or prescription plan name. This may be prepopulated if the plan makes the form available on their website. Include the health plan phone number and fax number for submission.
4. Section B requires you to enter the patient information. Fill in the patient's name, gender, date of birth, and member ID number.
5. In section C, fill out the prescriber information, including their name, phone number, specialty, secure fax number, NPI number, and DEA/xDEA. If the point of contact is different from the prescribing clinician, provide their details as well.
6. Section D focuses on medication information. Enter the medication being requested, its strength, quantity, dosing schedule, and length of therapy. Indicate whether the patient is currently being treated with the requested drug and provide any necessary details.
7. In section E, indicate if the medication is a compound and list the ingredients if applicable. If the request involves an off-label use, include a citation to peer-reviewed literature.
8. Section F requires patient clinical information. Fill in the primary diagnosis, ICD codes, pertinent comorbidities, drug allergies, height, weight, and any relevant concurrent medications. Provide details on opioid management tools in place and previous therapies tried or failed.
9. If the request is for reauthorization, answer if the patient has shown improvement while on therapy, along with any additional information pertinent to the request.
10. For professionally administered medications, complete the fields for start date, end date, servicing prescriber or facility name, and billing provider information.
11. After filling out all sections, review the form for accuracy. Users can then save changes, download, print, or share the form as necessary.

Complete your forms online today for a seamless authorization process.