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Fax completed prior authorization request form to 8552473677 (Integrated population) or 8552467736 (SMI Entitle population) or submit Electronic Prior Authorization through CoverMyMeds or Subscripts.
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It is a form used to request monoamine depletors.
Healthcare providers who prescribe or administer monoamine depletors.
The form must be completed with the patient's information, medical history, and the reason for requesting monoamine depletors.
To request the use of monoamine depletors for a specific patient.
Patient's name, date of birth, medical history, reason for requesting monoamine depletors, and healthcare provider's information.
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