Get Kalydeco Prior Authorization Physician Fax Form - Blue Cross And ...

This guide provides comprehensive instructions for completing the Kalydeco Prior Authorization Physician Fax Form online. By following these steps, you can ensure that all necessary information is accurately submitted for prior authorization.

Follow the steps to successfully fill out the form.

1. Click the ‘Get Form’ button to obtain the form and open it in your document editor.
2. Begin by filling in the patient information section. Enter today’s date, the patient's name (first and last), middle initial, date of birth (in mm/dd/yyyy format), address, city, state, zip code, and telephone number.
3. Next, move to the insurance information section. Provide the patient’s BCBS ID number and group number.
4. In the physician/clinic information section, enter the prescriber’s name, NPI number, specialty, clinic name, clinic address (including city, state, and zip), phone number, contact name, and secure fax number.
5. Provide any additional information that may support this request. Include the patient's diagnosis with the corresponding ICD-9 code and a description, along with the medication requested, its strength, dosing schedule, and quantity per month.
6. Indicate whether the patient is currently being treated with the requested medication and specify when the treatment began, if applicable. Also, confirm if the patient has the G551D mutation of the CFTR gene through an approved genetic test.
7. Outline the rationale for selecting the requested medication over alternatives, detailing any contraindications, allergies, or adverse reactions to other medications.
8. List all medications the patient is currently taking for the diagnosis and those previously attempted but failed, specifying whether they were brand-name, generic, or over-the-counter products.
9. Use the optional prescription order section to specify any ancillary supplies required, training needed for the patient, and ensure prescriber signature is included, along with the date.
10. Finalize the form by reviewing all sections for accuracy. You may save changes, download, print, or share the completed form as necessary.

Complete the Kalydeco Prior Authorization Physician Fax Form online and submit it today for timely processing.