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  • Massachusetts Standard Form For Medication Prior

Get Massachusetts Standard Form For Medication Prior

Uy and Bill). Start Date: End Date: Same as Prescribing Clinician Servicing Prescriber/Facility Name: Servicing Provider/Facility Address: Servicing Provider NPI/Tax ID #: Name of Billing Provider: Billing Provider NPI #: Is this a request for reauthorization? Yes No CPT Code: # of Visits: J Code: # of Units: Providers should consult the health plan s coverage policies, member benefits, and medical necessity guidelines to complete this form. Provider.

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All requests for Ozempic (semaglutide) require a prior authorization and will be screened for medical necessity and appropriateness using the criteria listed below.

You might be a candidate for Ozempic if you meet these criteria: You have Type 2 diabetes. Your A1C level is uncontrolled with other interventions. You have cardiovascular disease or are at a high risk of developing cardiovascular disease. You have kidney disease or heart failure.

For urgent or expedited requests please call 1-855-297-2870. This form may be used for non-urgent requests and faxed to 1-844-403-1029. OptumRx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations.

Ozempic® (semaglutide) injection 0.5 mg, 1 mg, or 2 mg is an injectable prescription medicine used: along with diet and exercise to improve blood sugar (glucose) in adults with type 2 diabetes mellitus.

Fax this form to: 1-866-434-5523 Phone: 1-866-434-5524 OptumRx will provide a response within 24 hours upon receipt.

Contact Phone. Main: Call MassHealth Customer Service Center for Providers, Main: at (800) 841-2900. Open Monday–Friday 8 a.m.–5 p.m. ... Online. Email Email MassHealth Customer Service Center for Providers at provider@masshealthquestions.com. Fax. (617) 988-8974.

Who Ozempic is prescribed for Obesity, defined as a body mass index (BMI) of 30 or greater. Overweight, defined as a BMI of 27 or greater, and at least one health condition related to weight. Examples include type 2 diabetes, high cholesterol, and high blood pressure.

What types of prescriptions require prior authorizations? Brand-name drugs that have a generic available. Drugs that are intended for certain age groups or conditions only. Drugs used only for cosmetic reasons. Drugs that are neither preventative nor used to treat non-life-threatening conditions.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232