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PRIOR AUTHORIZATION REQUEST FORM BMCHP 9. 168 Antidiabetic Agents - 2 Bydureon Glyxambi Invokana Invokamet XR Jardiance Jentadueto Kazano Kombiglyze XR Nesina Oseni Synjardy Tanzeum Trulicity and Version 12. If OTHER please specify Q11. Will the patient be utilizing a GLP-1 agonist i.e. Bydureon with a DPP-4 inhibitor i.e. Glyxambi /XR Kombiglyze XR Jantadueto Kazano Oseni Nesina Q12. Q9. If the patient has NOT tried a sulfonylurea thiazolidinedione TZD or please indicate which of the...

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How to fill out 168 antidiabetic agents

01

Step 1: Gather all necessary information and documents required to fill out the form.

02

Step 2: Start by entering the patient's personal information, including their full name, date of birth, and contact details.

03

Step 3: Provide the patient's medical history, including any previous diagnoses, current medications, and known allergies.

04

Step 4: Indicate the specific antidiabetic agents being prescribed by selecting the appropriate options from the provided list.

05

Step 5: Include the dosage instructions for each antidiabetic agent, specifying the frequency and timing of administration.

06

Step 6: If any additional instructions or notes are necessary, include them in the designated section of the form.

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Step 7: Review the completed form for accuracy and completeness, making any necessary corrections.

08

Step 8: Once satisfied with the filled-out form, submit it to the relevant healthcare provider or authority.

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Step 9: Keep a copy of the filled-out form for your records.

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Step 10: Follow any additional instructions or requirements provided by the healthcare provider or authority.

Who needs 168 antidiabetic agents?

01

Individuals diagnosed with type 2 diabetes or other forms of diabetes may require antidiabetic agents, including 168 antidiabetic agents.

02

Patients who are unable to control their blood sugar levels through diet and lifestyle changes alone may need to take antidiabetic agents.

03

Doctors may prescribe 168 antidiabetic agents to individuals with uncontrolled diabetes who have failed to respond to other treatment options.

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People with a family history of diabetes or risk factors for the disease may also benefit from taking antidiabetic agents.

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Ultimately, the decision of who needs 168 antidiabetic agents should be made by a qualified healthcare professional based on individual patient assessments.

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What is 168 antidiabetic agents?

168 antidiabetic agents refer to the list of medications used to treat diabetes.

Who is required to file 168 antidiabetic agents?

Healthcare professionals and facilities that prescribe or dispense antidiabetic agents are required to file 168 antidiabetic agents.

How to fill out 168 antidiabetic agents?

168 antidiabetic agents can be filled out by including the name, dosage, and quantity of antidiabetic agents prescribed or dispensed.

What is the purpose of 168 antidiabetic agents?

The purpose of 168 antidiabetic agents is to track the usage of antidiabetic medications and ensure proper monitoring of diabetes treatment.

What information must be reported on 168 antidiabetic agents?

The information reported on 168 antidiabetic agents includes the name of the medication, dosage prescribed, quantity dispensed, and patient information.

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