Get Dupixent (dupilumab) (non-preferred) Prior Authorization Form

This guide provides a comprehensive overview of how to complete the DUPIXENT (dupilumab) (non-preferred) PRIOR AUTHORIZATION FORM online. Following these detailed instructions will assist users in accurately filling out the required fields to facilitate the authorization process.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to receive the document and open it in your chosen editor.
2. Indicate whether this is a new request or a renewal request by selecting the appropriate option in the PRIOR AUTHORIZATION REQUEST INFORMATION section.
3. Fill in the number of pages in the specified field to ensure complete documentation.
4. Provide prescriber information, including the prescriber’s name, office contact name, specialty, contact phone number, state license number, long-term care facility contact number, and NPI.
5. Enter recipient information, including MA provider ID, street address, recipient's name, suite number, recipient ID, date of birth, city/state/zip, phone number, and fax number.
6. Complete the clinical information section by specifying the product requested (Dupixent 300 mg/2 ml syringe), directions, quantity, diagnosis, and required diagnosis code.
7. Indicate which specialty pharmacy will be used by selecting from Diplomat Specialty or Walgreens Specialty.
8. For initial requests, answer the questions regarding treatment history with topical corticosteroids, topical calcineurin inhibitors, phototherapy, and other medications. Check 'Yes' or 'No' as applicable and ensure you attach documentation of all prior treatments.
9. For renewal requests, confirm if the recipient has experienced a positive clinical response since starting Dupixent and provide supporting documentation as needed.
10. Finalize the form by obtaining the prescriber signature and date it before submission.
11. Once completed, fax the form along with the required clinical documentation to the DHS – Pharmacy Division.

Complete the form online and streamline your authorization request for DUPIXENT today.