TRICARE Prior Authorization Request Form
This TRICARE form is for obtaining prior authorization for liraglutide (Saxenda) and semaglutide (Wegovy). It must be completed by a prescriber for coverage through the TRICARE pharmacy program. Users should ensure to review all requirements before submission.
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How do I fill this out?
To fill out this form, gather all necessary patient and prescriber information. Ensure all questions are answered accurately based on the patient's medical history. Sign and date the form before submission.
How to fill out the TRICARE Prior Authorization Request Form?
1
Gather patient and physician information.
2
Complete the clinical assessment thoroughly.
3
Answer the questions regarding medical history and existing medications.
4
Sign and date the form.
5
Submit the form via fax, mail, or email as specified.
Who needs the TRICARE Prior Authorization Request Form?
1
Prescribing physicians who require authorization for patients.
2
Active Duty Service Members needing medication prior approval.
3
Patients prescribed with Saxenda or Wegovy for weight management.
4
Healthcare facilities processing TRICARE prescriptions.
5
Pharmacies filling TRICARE prescriptions needing verification.
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What are the instructions for submitting this form?
Submit the completed form by fax to 1-866-684-4477, or mail it to Express Scripts, P.O. Box 52150, Phoenix, AZ 85072-9954. You can also email the form to TPharmPA@express-scripts.com. Ensure accurate information to prevent delays.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, keep in mind that prior authorizations must be updated annually. Initial approvals are valid for 6 months with renewals for 12 months. Always check with TRICARE for the latest updates on policies and requirements.
What is the purpose of this form?
The purpose of this form is to facilitate the process of obtaining prior authorization for specific weight loss medications under TRICARE. It ensures that patients meet specific clinical criteria before medications are dispensed. By requiring detailed information, the form helps streamline approval for necessary treatments.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient receiving treatment.
- 2. Physician Name: The full name of the prescriber completing the form.
- 3. Sponsor ID #: The identification number of the TRICARE sponsor.
- 4. Date of Birth: The birth date of the patient.
- 5. Clinical Assessment: Questions regarding the patient's health history and medications.
- 6. Signature: Area for the prescriber to sign and date the form.
What happens if I fail to submit this form?
Failure to submit this form may result in denial of coverage for prescribed medications. This can lead to delays in treatment and additional costs for patients. It is essential to follow submission guidelines to avoid any complications.
- Denial of Medication: Not submitting the form can lead to patients not receiving the necessary medications.
- Additional Costs: Patients may incur out-of-pocket expenses if coverage is not approved.
- Treatment Delays: Missing the submission could delay important medical treatments.
How do I know when to use this form?
- 1. When prescribed Saxenda: Use this form to request prior approval for Saxenda.
- 2. When prescribed Wegovy: Utilize this form for obtaining authorization for Wegovy.
- 3. For Active Duty Members: This form is specifically required for active duty service members to access these medications.
Frequently Asked Questions
What is the purpose of this form?
The form is used to request prior authorization from TRICARE for specific weight management medications.
Who needs to fill out this form?
It should be completed by prescribing physicians for their patients needing authorization.
How do I submit this form?
You can submit the completed form via fax, mail, or email as per the instructions provided.
Is there a deadline for submission?
There is no specific deadline; however, timely submission is encouraged for quicker processing.
What happens if my request is denied?
You can appeal the decision through the appropriate Military Treatment Facility.
Can I edit this form after downloading?
Yes, you can edit the form using PrintFriendly's editing tools.
Do I need to include my signature?
Yes, a signature is required at the end of the form.
How can I share the form after editing?
You can generate a shareable link for easy distribution.
Can the patient submit the form directly?
Yes, patients can also submit the form with the prescription.
Where should I send the faxed form?
Fax it to the number provided in the instructions.
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