Brand Over Generic Prior Authorization Request Form
This form is designed for prescribers to request prior authorization for brand name medications when generic alternatives are not suitable. It is specifically meant for use within the DoD and TRICARE pharmacy program. Complete the form accurately to ensure timely processing and approval.
Edit, Download, and Sign the Brand Over Generic Prior Authorization Request Form
Form
eSign
Add Annotation
Share Form
How do I fill this out?
To fill out this form, start by entering your patient and physician's information in the designated sections. Make sure to clearly indicate the medication being prescribed. Follow each step carefully to provide any necessary justifications for the use of a brand name drug.
How to fill out the Brand Over Generic Prior Authorization Request Form?
1
Step 1: Complete patient and physician information.
2
Step 2: Indicate the medication being prescribed.
3
Step 3: Answer whether the patient has tried the generic product.
4
Step 4: Provide explanations or justifications as needed.
5
Step 5: Sign and date the form to certify accuracy.
Who needs the Brand Over Generic Prior Authorization Request Form?
1
Prescribers who need to justify a brand prescription.
2
Pharmacists who must process the authorization in line with regulations.
3
Patients seeking brand name medications due to specific medical needs.
4
Healthcare providers coordinating care that requires brand prescriptions.
5
Insurance coordinators responsible for managing medication costs.
How PrintFriendly Works
At PrintFriendly.com, you can edit, sign, share, and download the Brand Over Generic Prior Authorization Request Form along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.
Edit your Brand Over Generic Prior Authorization Request Form online.
Edit this PDF easily on PrintFriendly by uploading your file and selecting the edit option. You can modify text, adjust formatting, and ensure the document meets your needs. Enjoy a user-friendly interface that simplifies your editing experience.
Add your legally-binding signature.
On PrintFriendly, you can sign this PDF document by navigating to the signature section and using our digital signature tools. This allows for a quick and secure addition of your signature. Ensure your signature is applied before submitting the form.
Share your form instantly.
Sharing your PDF is effortless on PrintFriendly. Simply use the share functionality to send your edited document via email or social media links. Keep your recipients informed and ensure they receive the necessary documentation.
How do I edit the Brand Over Generic Prior Authorization Request Form online?
Edit this PDF easily on PrintFriendly by uploading your file and selecting the edit option. You can modify text, adjust formatting, and ensure the document meets your needs. Enjoy a user-friendly interface that simplifies your editing experience.
1
Step 1: Upload the PDF file you wish to edit.
2
Step 2: Access the editing tools from the toolbar.
3
Step 3: Make desired changes to text and layout.
4
Step 4: Preview the edited PDF to check your changes.
5
Step 5: Save the file or download it directly to your device.
What are the instructions for submitting this form?
To submit the completed Brand Over Generic Prior Authorization Request Form, you can fax it to 1-866-684-4477 or mail it to Express Scripts, P.O. Box 52150, Phoenix, AZ 85072-9954. You may also email the form to TpharmPA@express-scripts.com for quicker processing. Ensure all sections of the form are complete to prevent any delays in approval.
What are the important dates for this form in 2024 and 2025?
It is essential to stay updated with any revisions made to this form, particularly in August 2021, as regulations may change. Ensure that you are using the most current version before submission to avoid delays. Regular check-ins on the specified website for criteria updates are advisable.
What is the purpose of this form?
The purpose of the Brand Over Generic Prior Authorization Request Form is to provide a standardized method for prescribers to seek approval for a brand name medication when a generic alternative is clinically inappropriate. This ensures that patients receive the medications best suited for their needs while adhering to Department of Defense guidelines. By using this form, prescribers can facilitate a smooth authorization process, leading to better patient outcomes.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Enter the full name of the patient.
- 2. Physician Name: Provide the full name of the prescribing physician.
- 3. Sponsor ID #: Include the Sponsor ID number for identification.
- 4. Date of Birth: Enter the patient's date of birth.
- 5. Phone #: Provide a contact phone number.
- 6. Secure Fax #: Include a secure fax number for submission.
What happens if I fail to submit this form?
Failing to submit this form may result in delays in obtaining necessary medications for the patient. Without the required authorization, the prescribed brand name medication may not be covered under insurance, leading to higher out-of-pocket costs. Timely submission is crucial to ensure adherence to the treatment plan.
- Delay in Medication: Patients may face delays in receiving their medications.
- Increased Costs: Without pre-approval, out-of-pocket expenses may rise significantly.
- Non-Compliance Issues: Without necessary approvals, patients may not adhere to their prescribed treatments.
How do I know when to use this form?
- 1. When a Generic is Ineffective: Use this form if a patient has not had success with a generic alternative.
- 2. Specific Health Conditions: When certain conditions require a specific brand medication.
- 3. Insurance Requirement: When insurance plans stipulate the use of this form for brand prescriptions.
Frequently Asked Questions
What is the purpose of this form?
This form allows prescribers to request authorization for a brand name medication when a generic is not suitable.
How do I submit this form?
You can submit the completed form via fax, mail, or email as specified in the instructions.
Who needs to fill out this form?
Prescribers, patients, and healthcare providers dealing with medication approvals need to use this form.
Can I edit this document online?
Yes, you can easily edit this PDF using the editing features on PrintFriendly.
Where do I send the completed form?
Send the completed form to Express Scripts at the addresses provided in the submission instructions.
Is there a fee associated with this form?
There are no fees for filling out or submitting this form.
How long will it take to get approval?
Approval times can vary, but submitting a complete and accurate form will expedite the process.
What if I need to change my prescription after submitting?
You will need to fill out a new form with the updated prescription details.
What information do I need to provide?
You will need to provide patient and prescriber details, medication information, and justifications as needed.
Can I print this form after editing?
Yes, once you finish editing, you can print the updated document directly from PrintFriendly.
Related Documents - Prior Authorization Request
Preparticipation Physical Evaluation Form
The Preparticipation Physical Evaluation Form is used to assess the physical health and fitness of individuals before they participate in sports activities. It covers medical history, heart health, bone and joint health, and other relevant medical questions.
Health Insurance Tax Credits Guide 2015
This document provides a comprehensive guide on health insurance and premium tax credits for the 2015 tax year. It explains the tax filing rules, eligibility criteria, and detailed instructions for claiming and reporting premium tax credits. Essential for individuals who bought health insurance through the ACA Marketplaces.
TSP-77 Partial Withdrawal Request for Separated Employees
The TSP-77 form is used by separated employees to request a partial withdrawal from their Thrift Savings Plan account. It includes instructions for completing the form, certification, and notarization requirements. The form must be filled out completely and submitted along with necessary supporting documents.
Ray's Food Place Donation Request Form Details
This file contains the donation request form for Ray's Food Place. Complete the general information section and follow the guidelines to submit your donation request at least 30 days in advance. The form includes fields for organization details and donation specifics.
Pastoral Ministry Evaluation Form for Board of Elders
This evaluation form is designed for the Board of Elders to assess and provide feedback on a pastor's ministry. It aims to offer affirmation and identify areas for improvement. The form covers preaching, worship leading, pastoral care, administration, and more.
Health Provider Screening Form for PEEHIP Healthcare
This file contains the Health Provider Screening Form for PEEHIP public education employees and spouses. It includes instructions on how to fill out the form for wellness program participation. The form collects personal, medical, and screening details to assess wellness.
Common Law Marriage Declaration Form for FEHB Program
This form is used to declare a common law marriage for the purpose of enrolling a spouse under the Federal Employees Health Benefits (FEHB) Program. It requires personal details, marriage information, and additional documentation. Submission instructions and legal implications are included.
MyPRALUENT™ Enrollment Form Instructions and Details
This document provides comprehensive instructions and details for enrolling in the MyPRALUENT™ program, including benefits, patient assistance, and clinical support. It outlines the required patient, insurance, and prescriber information, as well as the steps for treatment verification and household income documentation.
Application for Certified Copy of Birth Certificate
This form is used to request a certified copy of a birth certificate from the Clerk of Court Office. It includes details about the applicant, the person named on the certificate, and requires a photo ID and the correct fee. This form is only for walk-in services.
Torrance Memorial Physician Network Forms for Patients 18+
This file contains important forms for patients 18 years and older registered with Torrance Memorial Physician Network. It includes patient registration, acknowledgment of receipt of privacy practices, and financial & assignment of benefits policy forms. Complete these forms to ensure your medical records are up-to-date and to understand your financial responsibilities.
Vodafone Phone Unlocking Guide: Steps to Unlock Your Phone
This guide from Vodafone provides a step-by-step process to unlock your phone. Learn how to obtain your unlock code by filling out an online form. Follow the instructions to complete the unlocking process.
Texas Automobile Club Agent Application Form
This file is the Texas Automobile Club Agent Application or Renewal form, which must be submitted within 30 days after hiring an agent. The form includes fields for agent identification, moral character information, and requires signature from both the agent and an authorized representative of the automobile club. Filing fees and submission instructions are also provided.
