Flector Prior Authorization Request Form (Page 1 of 2) 2026

1. Click ‘Get Form’ to open the Flector Prior Authorization Request Form in the editor.
2. Begin by filling out the 'Member Information' section. Enter the member's name, insurance ID number, date of birth, and contact details including phone and address.
3. Next, complete the 'Provider Information' section. Input the provider's name, NPI number, office phone and fax numbers, along with their address.
4. In the 'Medication Information' section, specify the medication name and strength. Indicate if you are requesting a brand version or if this is a continuation of therapy.
5. Proceed to 'Clinical Information'. Select the appropriate diagnosis from the options provided and fill in any required ICD-10 codes. Answer all clinical questions regarding medication usage and patient history.
6. Finally, provide details for quantity limit requests if applicable. Specify reasons for exceeding plan limitations as needed.

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