Get the free Aubagio – CSU Fax Form

This document is a prior approval request form for the prescription drug Aubagio, requiring information from both the cardholder and the prescribing physician to process claims for prescription drugs.

How to fill out aubagio csu fax form

How to fill out Aubagio – CSU Fax Form

1. Obtain the Aubagio – CSU Fax Form from the healthcare provider or online.
2. Fill in the patient's personal information, including full name, date of birth, and contact details.
3. Provide the insurance information, including the provider's name and policy number.
4. Indicate the medication dosage and frequency as prescribed by the healthcare provider.
5. Include the physician's information, including name, contact number, and signature.
6. Add any relevant medical history or notes required for processing the request.
7. Double-check all information for accuracy and completeness.
8. Fax the completed form to the appropriate CSU number provided on the form.

Who needs Aubagio – CSU Fax Form?

1. Patients prescribed Aubagio who require prior authorization for medication.
2. Healthcare providers assisting patients with the prescription process.
3. Pharmacies needing to verify insurance and medication coverage.

People Also Ask about

What is the fax number for prime therapeutics prior authorization form?

The Prescription Drug Prior Authorization form may be completed by the prescriber and faxed to Prime Therapeutics Management at 800-424-3260. For drug specific forms please see the Forms tab under Resources.

How much is a 30 day supply of Aubagio?

Reddy's, Glenmark, Teva, Camber, Alembic, Apotex, Aurobindo, and Sola. Price: The wholesale acquisition cost of teriflunomide has been reported to be between $32.40 - $2,058.90 per 30-day supply. Aubagio currently costs approximately $9,155.25 per month as of February 15, 2023.

What is the fax number for ProAct prior authorization?

ProAct. Prescribers can submit requests for prior authorization by submitting, via fax to ProAct, at 1-844-712-8129. Please note: Prior authorization forms submitted are subject to validation against both member-specific prescription drug coverage and clinical criteria guidelines.

What is a prior authorization number?

Prior authorization, also known as pre-authorization or pre-certification, allows health insurance plans to review proposed care ahead of time, confirm that coverage for the service is available under the plan, and give the medical provider approval to go ahead with the procedure or prescription.

What is the fax number for prime therapeutics prior authorization?

The Prescription Drug Prior Authorization form may be completed by the prescriber and faxed to Prime Therapeutics Management at 800-424-3260. For drug specific forms please see the Forms tab under Resources.

For pdfFiller’s FAQs

What is Aubagio – CSU Fax Form?

Aubagio – CSU Fax Form is a documentation form used for the submission of patient information and insurance claims related to the medication Aubagio.

Who is required to file Aubagio – CSU Fax Form?

Healthcare providers who are prescribing Aubagio to patients are required to file the Aubagio – CSU Fax Form for insurance processing and reimbursement.

How to fill out Aubagio – CSU Fax Form?

To fill out the Aubagio – CSU Fax Form, provide patient demographics, insurance details, prescribing information, and any necessary medical history in the designated sections of the form.

What is the purpose of Aubagio – CSU Fax Form?

The purpose of the Aubagio – CSU Fax Form is to streamline the process of obtaining insurance authorization and to ensure that necessary patient information is communicated for treatment coordination.

What information must be reported on Aubagio – CSU Fax Form?

The Aubagio – CSU Fax Form must report patient identification details, insurance policy information, dosage and prescribing information, diagnosis codes, and any relevant medical history or notes necessary for claim submission.