Instructions for form f 11075 prior authorization 2011-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with SECTION I — MEMBER INFORMATION. Fill in the member's name, identification number, and date of birth clearly.
3. Proceed to SECTION II — PRESCRIPTION INFORMATION. Enter the drug name, strength, date written, directions for use, prescriber’s name, NPI, address, and telephone number.
4. In SECTION III — CLINICAL INFORMATION, provide the diagnosis code and description. Answer questions regarding treatment failures and medical conditions that prevent the use of preferred drugs.
5. Continue filling out any clinically significant interactions or adverse reactions experienced by the member in SECTION III.
6. Complete SECTION IV if applicable for pharmacy providers using STAT-PA by entering the National Drug Code, days' supply requested, NPI, date of service, place of service, assigned PA number, grant date, expiration date, and number of days approved.
7. Finally, add any additional information in SECTION V as needed before saving your completed form.

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