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SPECIAL AUTHORIZATION REQUEST Semaglutide Fax requests to (902) 3684905, email to drugprograms@gov.pe.ca OR mail requests to PEI Pharmacies, P.O. Box 2000, Charlottetown, PE, C1A 7N8SECTION 1 PRESCRIBER

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How to fill out special authorization request semaglutide

01

Obtain the special authorization request form for semaglutide from the appropriate authority or healthcare provider.

02

Fill out the patient's information including name, date of birth, contact information, and health card number.

03

Provide details about the medical condition that requires treatment with semaglutide, including previous treatments tried and their effectiveness.

04

Include any supporting medical documentation such as test results or physician notes to justify the need for semaglutide.

05

Submit the completed form and supporting documents to the designated authority for review and approval.

Who needs special authorization request semaglutide?

01

Patients who have been prescribed semaglutide by their healthcare provider but require special authorization to access the medication due to specific criteria set by the healthcare system or insurance provider.

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What is special authorization request semaglutide?

Special authorization request semaglutide is a process where a healthcare provider requests approval for the use of the medication semaglutide for a specific patient when standard treatment options have been exhausted.

Who is required to file special authorization request semaglutide?

A healthcare provider such as a doctor or nurse practitioner is required to file the special authorization request for semaglutide.

How to fill out special authorization request semaglutide?

The healthcare provider must complete the necessary paperwork, include supporting medical documentation, and submit the request to the appropriate authority for review.

What is the purpose of special authorization request semaglutide?

The purpose of the special authorization request for semaglutide is to ensure that patients who may benefit from the medication have access to it, even if it is not typically covered by their insurance.

What information must be reported on special authorization request semaglutide?

The special authorization request for semaglutide must include details about the patient's medical history, previous treatments, and reasons why semaglutide is being requested.

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