Get () & Yuvafem Prior Authorization Request Form (page 1 Of 2)

Filling out the ® & Yuvafem™ Prior Authorization Request Form can be straightforward when you follow the right steps. This guide provides clear, step-by-step instructions to help ensure that all required information is accurately submitted for timely processing.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the Member Information section, fill in the required fields: Member Name, Insurance ID#, Date of Birth, Street Address, City, State, and Zip code. Ensure accuracy as this information is essential for processing.
3. Complete the Provider Information section, including Provider Name, NPI#, Office Phone, Office Fax, and Specialty. Use the corresponding office street address, city, state, and zip code.
4. Proceed to the Medication Information section. Write the Medication Name and Strength. Indicate whether you are requesting the brand by checking the box and specify if this is a request for continuation of therapy.
5. Provide Directions for Use and Dosage Form relevant to the medication being requested.
6. In the Clinical Information section, select the applicable diagnosis by checking the appropriate box. Fill in any other diagnoses in the space provided and include ICD-10 code(s).
7. Indicate any medications that the patient has a failure, contraindication, or intolerance to by checking the relevant boxes for dyspareunia and vaginal atrophy.
8. For Quantity Limit Requests, enter the quantity requested per day and provide a reason for exceeding plan limitations. Check the appropriate box for justification and specify any unique cases.
9. If necessary, include any additional comments, diagnoses, or symptoms related to the patient’s situation at the end of the form.
10. Once all sections are completed, review the information for accuracy. You may then save changes, download, print, or share the filled form as needed.

Complete your forms online today for a smoother submission process!