PRIOR APPROVAL REQUEST Member Information: Fill out & sign online

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Click ‘Get Form’ to open the PRIOR APPROVAL REQUEST Member Information in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's first and last name, address, date of birth, and contact numbers. Ensure all fields are legible.
In the 'Insurance Information' section, indicate if the patient has other coverage. If yes, provide the necessary ID numbers and details.
Complete the 'Prescriber Information' section by entering the prescriber's details including their name, address, phone number, and specialty.
Fill out the 'Dispensing Provider/Administration Information' to specify where and how the medication will be administered.
In 'Product Information', indicate that the request is for Lucentis (ranibizumab) along with dosage and directions for use.
Provide diagnosis information by entering primary ICD codes in the designated fields.
Complete any required clinical information based on your specific request type before signing off in the 'Acknowledgement' section.

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