Get the free Emsam (selegiline) PRIOR AUTHORIZATION FORM

This form is used to request prior authorization for the Emsam patch for patients diagnosed with major depressive disorder who meet specific treatment guidelines.

How to fill out emsam selegiline prior authorization

How to fill out Emsam (selegiline) PRIOR AUTHORIZATION FORM

1. Obtain the Emsam (selegiline) Prior Authorization Form from your healthcare provider or insurance company's website.
2. Fill in the patient's personal information at the top of the form, including name, date of birth, and insurance details.
3. Provide the prescribing physician's information, including name, contact number, and practice address.
4. Indicate the diagnosis for which Emsam is being prescribed, including any relevant ICD codes.
5. Document previous treatments and medications tried, along with their outcomes.
6. Include the dosage information and duration for which Emsam is being prescribed.
7. Attach any supporting medical documentation that may help justify the need for Emsam.
8. Review the completed form for accuracy and completeness.
9. Submit the form to the appropriate insurance provider's fax number or online portal.
10. Follow up with the insurance company to check on the status of the prior authorization request.

Who needs Emsam (selegiline) PRIOR AUTHORIZATION FORM?

1. Patients who are prescribed Emsam (selegiline) for the treatment of major depressive disorder.
2. Healthcare providers who prescribe Emsam and need to obtain approval from insurance before dispensing the medication.
3. Individuals who have insurance plans that require prior authorization for certain medications, including Emsam.

People Also Ask about

What class of medication is EMSAM?

EMSAM (selegiline transdermal system) is a monoamine oxidase inhibitor (MAOI) indicated for the treatment of adults with major depressive disorder (MDD) [see Clinical Studies].

What drug class is selegiline?

Selegiline is in a group of medications called monoamine oxidase type B (MAO-B) inhibitors. It works by increasing the amount of dopamine (a natural substance that is needed to control movement) in the brain.

What is the indication of selegiline EMSAM?

® (selegiline transdermal system) is a monoamine oxidase inhibitor (MAOI) indicated for the treatment of major depressive disorder (MDD) (1) (14.1). once every 24 hours (2.1). Initial Treatment: The recommended starting dose and target dose for EMSAM is 6 mg per 24 hours (2.1).

What class of drug is Nefazodone?

Nefazodone is used to treat depression. Nefazodone is in a class of medications called serotonin modulators. It works by increasing the amounts of certain natural substances in the brain that are needed to maintain mental balance.

What are the contraindications for EMSAM?

EMSAM (selegiline transdermal system) is contraindicated with selective serotonin reuptake inhibitors (SSRIs, e.g., fluoxetine, sertraline, and paroxetine); dual serotonin and norepinephrine reuptake inhibitors (SNRIs, e.g., venlafaxine and duloxetine); tricyclic antidepressants (TCAs, e.g., imipramine and

What class of drugs are MAOI?

Monoamine oxidase inhibitors (MAOIs) are a separate class from other antidepressants, treating different forms of depression and other nervous system disorders such as panic disorder, social phobia, and depression with atypical features.

What is a prior authorization form for medication?

Prior authorization (PA) is an essential tool that is used to ensure that drug benefits are administered as designed and that plan members receive the medication therapy that is safe, effective for their condition, and provides the greatest value.

What class of drug is EMSAM?

Emsam belongs to a group of medicines called monoamine oxidase inhibitors (MAOI).

For pdfFiller’s FAQs

What is Emsam (selegiline) PRIOR AUTHORIZATION FORM?

Emsam (selegiline) PRIOR AUTHORIZATION FORM is a document required by health insurance companies to determine whether they will cover the medication Emsam for a patient. It ensures that the prescribing physician has provided sufficient documentation regarding the medical necessity of the drug.

Who is required to file Emsam (selegiline) PRIOR AUTHORIZATION FORM?

The prescribing physician or healthcare provider is typically required to file the Emsam (selegiline) PRIOR AUTHORIZATION FORM on behalf of the patient to the insurance company.

How to fill out Emsam (selegiline) PRIOR AUTHORIZATION FORM?

To fill out the Emsam (selegiline) PRIOR AUTHORIZATION FORM, the physician needs to complete sections that include patient information, details about the prescribed medication, clinical diagnosis, previous treatments tried, and the rationale for using Emsam.

What is the purpose of Emsam (selegiline) PRIOR AUTHORIZATION FORM?

The purpose of the Emsam (selegiline) PRIOR AUTHORIZATION FORM is to provide the insurance provider with necessary information to evaluate the medical necessity and appropriateness of prescribing Emsam for a specific patient, ensuring that coverage for the medication can be approved.

What information must be reported on Emsam (selegiline) PRIOR AUTHORIZATION FORM?

The information that must be reported on the Emsam (selegiline) PRIOR AUTHORIZATION FORM typically includes patient demographics, diagnosis, previous medications attempted, treatment history, and justification for why Emsam is the appropriate treatment choice.