Get Indiana University Health Plans Prior Authorization Form 2015-2025

Completing the Indiana University Health Plans Prior Authorization Form online is a straightforward process that ensures your medication needs are addressed promptly. This guide will walk you through each section of the form to help you complete it accurately and efficiently.

Follow the steps to fill out the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the demographics section. Provide the patient’s name, date of birth, age, health plan ID, and pharmacy information, including pharmacy name and contact number.
3. Next, complete the prescriber information. Input the prescriber’s name, NPI number, and contact details.
4. In the medication information section, indicate the drug requested, its strength, directions for use, quantity dispensed, and day supply. Specify if a brand name is necessary.
5. If the request is for continuation of therapy, attach the required chart documentation and indicate the start date.
6. Proceed to the billing information section. Specify if billing is by a specialty pharmacy or under medical benefits. Complete any necessary JCODE and ICD-10 code.
7. In the clinical information section, detail the disease severity, PPD test results, and any current therapies the member is using.
8. You will need to document any previous medications tried and their outcomes. Include dates, doses, and reasons for discontinuation for each medication.
9. Continue through the questions about trial failures for various medications and treatments relevant to the patient’s condition.
10. Finally, after ensuring all necessary sections are completed, users can save changes, download, print, or share the form as needed.

Complete your Indiana University Health Plans Prior Authorization Form online today.