Get Nm Evicore Healthcare Drug Prior Authorization Request Form

This guide offers clear instructions for completing the NM EviCore Healthcare Drug Prior Authorization Request Form online. By following these steps, you will ensure that your request is submitted correctly and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the NM EviCore Healthcare Drug Prior Authorization Request Form and open it for editing.
2. In blocks 1 and 2, provide the name of the insurer and the date of the request. Make sure to follow any specific instructions provided on the insurer’s website regarding submission.
3. In blocks 3, 4, and 5, enter the necessary coverage information to identify the insured member and their policy details.
4. For blocks 6 through 13, and 16 through 22, fill in the required patient information as indicated on the form, ensuring to complete any sections marked with an asterisk (*). Pay special attention to the BIN#, PCN#, and Issuer# details.
5. In blocks 14 and 15, although not required, provide patient contact information to assist pharmacies in reaching out if necessary.
6. Complete blocks 23 through 36 with the prescriber’s information, ensuring all mandatory fields are filled. Include the group practice or clinic name where applicable.
7. In blocks 37 through 49, provide comprehensive details regarding the requested medication, including dosages, anticipated duration of treatment, and any justifications for the request.
8. Fill out blocks 50 through 54 with pharmacy or dispensing entity information to streamline communication regarding the authorization with the appropriate pharmacy.
9. Once all fields are completed, review the form for accuracy, save your changes, and choose whether to download, print, or share the document as necessary.

Complete your NM EviCore Healthcare Drug Prior Authorization Request Form online today!