Get the free BCBSVT/TVHP Simponi PA Form
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This document is a prior approval form required by Blue Cross Blue Shield of Vermont and The Vermont Health Plan for the medication Simponi (Golimumab). It is used to collect necessary patient information
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How to fill out bcbsvttvhp simponi pa form
How to fill out BCBSVT/TVHP Simponi PA Form
01
Obtain the BCBSVT/TVHP Simponi PA Form from the official website or your healthcare provider.
02
Fill out the patient information section with the patient's full name, date of birth, and insurance details.
03
Provide the physician's information, including name, practice name, and contact details.
04
Indicate the medical diagnosis necessitating Simponi treatment with supporting documentation.
05
Fill in the prescribed dosage and frequency of the medication.
06
Include any previous treatments attempted and their outcomes.
07
Sign and date the form to authorize processing.
08
Submit the form along with any required documentation to the appropriate BCBSVT or TVHP office.
Who needs BCBSVT/TVHP Simponi PA Form?
01
Patients diagnosed with conditions like rheumatoid arthritis, psoriatic arthritis, or inflammatory bowel disease who are prescribed Simponi by their healthcare provider.
02
Healthcare providers submitting requests for prior authorization on behalf of their patients.
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People Also Ask about
What is the phone number for BCBS of Vermont prior authorization?
Download the prior approval form; fax the completed prior approval form(s) to (866) 387-7914. Call us directly for a pre-notification request. If calling, have the member name and certificate number ready, as well as the clinical details. Call us at (800) 922-8778.
What is the phone number for prior authorization for BCBS of California?
Phone: (800) 541-6652 7 a.m. to 5 p.m. PT, Monday through Friday, 8 a.m. to 5 p.m. PT, Saturday and Sunday.
What is the fax number for True Scripts prior authorization?
Once all necessary documentation is received, TrueScripts will complete the PA process in 24 – 48 Business hours. Prior Authorization Form may be sent via fax to 812-257-1968.
What is the fax number for Optum RX prior authorization?
For urgent or expedited requests please call 1-800-711-4555. This form may be used for non-urgent requests and faxed to 1-844-403-1027. Optum Rx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations.
What is the fax number for prior authorization BCBS of Vermont?
Submit pre-notification requests electronically via the Prior Authorization Portal by logging in to the Provider Resource Center. Download the prior approval form; fax the completed prior approval form(s) to (866) 387-7914.
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What is BCBSVT/TVHP Simponi PA Form?
The BCBSVT/TVHP Simponi PA Form is a prior authorization form required by Blue Cross Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP) for the prescription of Simponi, a medication used to treat certain autoimmune conditions.
Who is required to file BCBSVT/TVHP Simponi PA Form?
Healthcare providers prescribing Simponi on behalf of their patients are required to file the BCBSVT/TVHP Simponi PA Form to obtain prior authorization for the medication.
How to fill out BCBSVT/TVHP Simponi PA Form?
To fill out the BCBSVT/TVHP Simponi PA Form, healthcare providers need to provide patient information, medication details, clinical information justifying the need for the medication, and any relevant supporting documentation.
What is the purpose of BCBSVT/TVHP Simponi PA Form?
The purpose of the BCBSVT/TVHP Simponi PA Form is to ensure appropriate use of Simponi, helping the insurance provider assess the medical necessity and patient eligibility for the treatment before authorization.
What information must be reported on BCBSVT/TVHP Simponi PA Form?
The form must report information such as patient's name, date of birth, insurance details, diagnosis, prior treatments attempted, clinical notes, and any other information that supports the necessity of Simponi for the patient's condition.
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