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How to use or fill out Vagifem® & Yuvafem™ Prior Authorization Request Form (Page 1 of 2) with our platform

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Member Information' section. Enter the member's name, insurance ID number, date of birth, and contact details.
Next, complete the 'Provider Information' section. Input the provider's name, NPI number, office phone, and address.
In the 'Medication Information' section, specify the medication name and strength. Indicate if you are requesting a brand and if this is for continuation of therapy.
Proceed to 'Clinical Information'. Select the appropriate diagnosis and provide any relevant ICD-10 codes. List any medications that have been tried and failed.
Finally, fill in any additional comments or necessary information that may assist in processing this request.

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