Get Blue Advantage Bcbs Medicare Part D Prescription Drug Authorization Request Form 2011
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How to fill out the Blue Advantage BCBS Medicare Part D Prescription Drug Authorization Request Form online
Filling out the Blue Advantage BCBS Medicare Part D Prescription Drug Authorization Request Form online is a straightforward process that requires careful attention to detail. This guide will walk you through each section of the form, ensuring that you provide all necessary information for a successful authorization request.
Follow the steps to complete your authorization request form online.
- Click ‘Get Form’ button to access the form and open it in your editing tool.
- In the general information section, indicate the type of request by checking one of the boxes: Prior Authorization, Step Therapy Exception, Request Non-formulary Drug, Request for Quantity Limit Exception, or Appeal. Fill in the patient's name, date of birth, home address, contract number, city, state, zip code, and phone number accurately.
- For the physician information section, enter the physician's name and practice type (PCP or Specialist). Provide the practice address, city, state, zip code, office phone, office fax, and provider number to ensure proper identification and contact.
- In the drug information section, specify the drug requested, the dose requested, the reason for use, and the related ICD-9 code. Include the duration of the disease and detail any other medications the patient has tried for this condition along with their regimen and dates of therapy.
- If applicable, indicate whether the patient has any co-morbid conditions that could affect therapy by selecting 'Yes' or 'No', and list these conditions if necessary.
- At the bottom of the form, the physician must certify the information is correct by providing their signature and the date. Ensure that this section is also completed before submission.
- Once the form is fully completed, you have the option to save changes, download, print, or share the form as needed. Submissions can be sent via fax to the Clinical Review Department or mailed to the specified address.
Start filling out your Blue Advantage BCBS Medicare Part D Prescription Drug Authorization Request Form online today!
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Yes, many Medicare Advantage plans include Part D drug coverage in their offerings. This integration allows you to have your medical and prescription needs managed under one plan, which is convenient. To smoothly navigate these options, you might find the Blue Advantage BCBS Medicare Part D Prescription Drug Authorization Request Form helpful.
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