Get 2014-2025

Filling out the Pegol (®) preauthorization request form online is a straightforward process. This guide will lead you through each section of the form to ensure you provide accurate and complete information.

Follow the steps to successfully complete the preauthorization request.

1. Click ‘Get Form’ button to access the preauthorization request form and open it in your preferred online editor.
2. Enter the initial start date of therapy and the anticipated date of the next injection in Section I – General Information.
3. In Section II – Member Information, fill in the member's name, plan type, member ID, date of birth, and any additional details required.
4. Proceed to Section III – Provider Information Required. Fill in the requesting provider's name, address, telephone number, office contact name, place of service, CBC number, NPI number, fax number, and office contact telephone number.
5. In Section IV – Preauthorization Requirements and Clinical Criteria, indicate the diagnosis, diagnosis code, and specify whether a consultation with a rheumatologist or gastroenterologist has been obtained.
6. Answer questions regarding tuberculosis testing and document any medical contraindications for self-administration of (®). Attach any necessary clinic notes as directed.
7. For Crohn’s Disease and Rheumatoid Arthritis, if applicable, complete Section IV A by listing previous medications tried, including trial dates and reasons for discontinuation.
8. If reauthorization is necessary, provide updated information regarding tuberculosis testing and improvements measured by a standardized disease activity tool.
9. Lastly, sign and date the form in Section V – Required Physician Signature to finalize the submission.
10. After completing the form, you can save changes, download, print, or share the preauthorization request form as needed.

Complete your preauthorization request online today for a smoother submission process.