You will need to use a generic HCPC code of J3490 along with your diagnosis. Then be sure to add the name of the drug in the drug section with the dosage.

You can anticipate a determination on the preauthorization request within 15 days of receipt of your request. Delays in the process can be avoided by ensuring this form is complete and the appropriate codes and supporting documentation are included.

Please fax your medical records to 877-232-6726 with your submission reference number noted on the header page and include the patient's ID number.