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

Filling out the Fiasp & Fiasp FlexTouch Prior Authorization Request Form is an essential step in ensuring your medication needs are met efficiently. This guide provides clear instructions to help you complete the form online, ensuring all necessary information is submitted accurately.

Follow the steps to successfully complete your prior authorization request.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in the 'Member Information' section. Include the member's name, insurance ID number, date of birth, street address, city, state, zip code, and contact information.
3. Complete the 'Provider Information' section. Provide the provider's name, NPI number, street address, office phone number, office fax number, and specialty.
4. In the 'Medication Information' section, input the medication name, strength, and check the box if you are requesting the brand version. Enter the directions for use and dosage form.
5. Proceed to the 'Clinical Information' section. Select the requested drug (Fiasp FlexTouch or Fiasp vial) and answer the questions regarding the patient's therapy history, including continuation status and prior medications.
6. Provide the diagnosis related to the medication request, along with any relevant ICD-10 codes.
7. In the reauthorization section, confirm the member's current use of the requested medication and any positive clinical response.
8. Specify the quantity requested per month and indicate if higher quantities are necessary for blood glucose control.
9. Review all completed sections for accuracy. Ensure all required fields are filled out before proceeding.
10. Save your changes, download, print, or share the form as needed to submit it through the appropriate channels.

Start filling out your prior authorization request form online to ensure timely responses and support.