Follow the steps to successfully complete your form

1. Press the ‘Get Form’ button to obtain the form and access it in your preferred viewing editor.
2. Begin by filling out the member information, including the member's name, date of birth, and insurance ID number. Make sure to provide accurate and up-to-date details.
3. Next, provide the provider information. Include the provider's name, office phone number, NPI number, and relevant street address details to ensure proper routing.
4. Move to the medication information section. Fill in the medication name, strength, and indicate if you are requesting the brand version or if this is for a continuation of therapy.
5. In the clinical information section, answer whether this request is for a continuation of prior therapy. If yes, you must submit supporting documentation and details regarding previous treatments.
6. Select the diagnosis from the provided list, ensuring you include any additional details or codes as necessary.
7. In the medication history field, indicate whether the patient has prior use of specific alternatives and if any are contraindicated. Accurate reporting is crucial to the approval process.
8. Specify the quantity requested per day and provide justification if this exceeds plan limitations. Select options that best explain the needs related to dosing.
9. Answer supplementary questions regarding potential withdrawal symptoms or safety concerns linked to discontinuation of therapy, ensuring thorough documentation for review.
10. If necessary, add any additional comments or relevant information that may support the request. Users should ensure all provided information is complete.
11. Finally, review the completed form for accuracy. You can then save changes, download, print, or share the form as needed.

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