"Prior Authorization Form - Brand Nsaid Step Therapy - Express Scripts"

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Prior Authorization Form
Brand NSAID Step Therapy
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-328-9799
applicable to all patients; certain plans and situations may require additional
information beyond what is specifically requested.
If this an URGENT request, please call 1-800-753-2851
Additional forms available:
www.express-scripts.com/pa
Patient Information
Prescriber Information
Patient First Name: ______________________________
Prescriber Name: _________________________________
Prescriber DEA/NPI (required): ______________________
Patient Last Name: _______________________________
Prescriber Phone #: _______________________________
Patient ID#: _____________________________________
Prescriber Fax #: _________________________________
Patient DOB: ____________________________________
Prescriber Address: _______________________________
Patient Phone #: _________________________________
State: ________________ Zip Code: __________________
Primary Diagnosis: _________________________________ ICD Code: ________________________________________
Please indicate which drug and strength is being requested:
Orudis 25mg
Anaprox 275mg
Lodine 300mg
Orudis 50mg
Anaprox DS 550mg
Lodine 400mg
Orudis 75mg
Ansaid 50mg
Lodine 500mg
Oruvail 100mg
Ansaid 100mg
Lodine XL 400mg
Oruvail 150mg
Arthrotec 50
Lodine XL 500mg
Oruvail 200mg
Arthrotec 75
Lodine XL 600mg
Pennsaid 1.5% Topical Solution
Cambia Powder
Mobic 7.5mg
Ponstel 250mg
Cataflam 50mg
Mobic 15mg
Prevacid Naprapac 375mg
Clinoril 150mg
Mobic 7.5mg/5ml Suspension
Prevacid Naprapac 500mg
Clinoril 200mg
Motrin 100mg/5ml Suspension
Relafen 500mg
Daypro 600mg
Motrin 200mg
Relafen 750mg
Daypro ALTA 600mg
Motrin 400mg
Sprix 15.75mg/actuation Nasal Spray
EC-Naprosyn 375mg
Motrin 600mg
Toradol 15mg/ml Injection
EC-Naprosyn 500mg
Motrin 800mg
Toradol 30mg/ml Injection
Feldene 10mg
Nalfon 200mg
Toradol 10mg Tablet
Feldene 20mg
Nalfon 300mg
Vimovo 375mg-20mg Delayed Release Tab
Flector 1.3% Topical Patch
Nalfon 400mg
Vimovo 500mg-20mg Delayed Release Tab
IC400 Kit
Naprelan 375mg
Voltaren 1% Topical Gel
IC800 Kit
Naprelan 500mg
Voltaren 25mg Tablet
Indocin 25mg
Naprelan 750mg
Voltaren 50mg Tablet
Indocin 50mg
Naprelan CR Dose Card
Voltaren 75mg Tablet
Indocin 25mg/5ml Suspension
Naprosyn 250mg
Voltaren-XR 100mg Tablet
Indocin SR 75mg
Naprosyn 375mg
Zipsor 25mg
Lodine 200mg
Naprosyn 500mg
Other:______________________________
Directions for use (i.e. QD, BID, PRN & Qty): _______________________________________________________________________
Please complete the clinical assessment:
 Yes
 No
 N/A
1. Is the patient currently taking the requested medication?
Prior Authorization Form
Brand NSAID Step Therapy
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-328-9799
applicable to all patients; certain plans and situations may require additional
information beyond what is specifically requested.
If this an URGENT request, please call 1-800-753-2851
Additional forms available:
www.express-scripts.com/pa
Patient Information
Prescriber Information
Patient First Name: ______________________________
Prescriber Name: _________________________________
Prescriber DEA/NPI (required): ______________________
Patient Last Name: _______________________________
Prescriber Phone #: _______________________________
Patient ID#: _____________________________________
Prescriber Fax #: _________________________________
Patient DOB: ____________________________________
Prescriber Address: _______________________________
Patient Phone #: _________________________________
State: ________________ Zip Code: __________________
Primary Diagnosis: _________________________________ ICD Code: ________________________________________
Please indicate which drug and strength is being requested:
Orudis 25mg
Anaprox 275mg
Lodine 300mg
Orudis 50mg
Anaprox DS 550mg
Lodine 400mg
Orudis 75mg
Ansaid 50mg
Lodine 500mg
Oruvail 100mg
Ansaid 100mg
Lodine XL 400mg
Oruvail 150mg
Arthrotec 50
Lodine XL 500mg
Oruvail 200mg
Arthrotec 75
Lodine XL 600mg
Pennsaid 1.5% Topical Solution
Cambia Powder
Mobic 7.5mg
Ponstel 250mg
Cataflam 50mg
Mobic 15mg
Prevacid Naprapac 375mg
Clinoril 150mg
Mobic 7.5mg/5ml Suspension
Prevacid Naprapac 500mg
Clinoril 200mg
Motrin 100mg/5ml Suspension
Relafen 500mg
Daypro 600mg
Motrin 200mg
Relafen 750mg
Daypro ALTA 600mg
Motrin 400mg
Sprix 15.75mg/actuation Nasal Spray
EC-Naprosyn 375mg
Motrin 600mg
Toradol 15mg/ml Injection
EC-Naprosyn 500mg
Motrin 800mg
Toradol 30mg/ml Injection
Feldene 10mg
Nalfon 200mg
Toradol 10mg Tablet
Feldene 20mg
Nalfon 300mg
Vimovo 375mg-20mg Delayed Release Tab
Flector 1.3% Topical Patch
Nalfon 400mg
Vimovo 500mg-20mg Delayed Release Tab
IC400 Kit
Naprelan 375mg
Voltaren 1% Topical Gel
IC800 Kit
Naprelan 500mg
Voltaren 25mg Tablet
Indocin 25mg
Naprelan 750mg
Voltaren 50mg Tablet
Indocin 50mg
Naprelan CR Dose Card
Voltaren 75mg Tablet
Indocin 25mg/5ml Suspension
Naprosyn 250mg
Voltaren-XR 100mg Tablet
Indocin SR 75mg
Naprosyn 375mg
Zipsor 25mg
Lodine 200mg
Naprosyn 500mg
Other:______________________________
Directions for use (i.e. QD, BID, PRN & Qty): _______________________________________________________________________
Please complete the clinical assessment:
 Yes
 No
 N/A
1. Is the patient currently taking the requested medication?
 Yes
 No
 N/A
2. Is the patient taking samples or paying 100% out of pocket for the medication being requested?
If no, please indicate:
Requested medication covered under previous insurance plan
Started medication in hospital
Other: ___________________________________________________________________
 Yes
 No
3. Has the patient tried two unique prescription-strength generic NSAIDs for the current
condition?
: _________________________
If yes, please provide names, strengths and directions
______________________________________________________________
 Yes
 No
 N/A
4. If prescribing Flector Patch, Sprix, Pennsaid, or Voltaren Gel only, is the patient unable to or has
difficulty swallowing?
 Yes
 No
 N/A
5. If prescribing Pennsaid or Voltaren Gel only, does the patient have a chronic musculoskeletal
pain condition (e.g., osteoarthritis)?
If yes, please document: _________________________________________________________
6. If prescribing Pennsaid or Voltaren Gel only, how many joints or sites is the requested medication being applied to?
Please list: __________________________________________________________________________________________________
 Yes
 No
 N/A
7. If prescribing Pennsaid or Voltaren Gel only, is the patient at risk of NSAID-associated toxicity?
If yes, what NSAID associated toxicity is the patient at risk for? _________________________
____________________________________________________________________________
Are there any other comments, diagnoses, symptoms, and/or any other information the physician feels
is important to this review?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Prescriber Signature: __________________________________________Date: ____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Office Contact Name: ___________________________ Phone Number: __________________________
__________________________________________________________________________________________
Based upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you have any
________________________________________________________________________________
questions about the process or required information, please contact our prior authorization team at the number listed on the top of this form.
Prior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician.
Only a treating physician can determine what medications are appropriate for the patient. Please refer to the applicable plan for the detailed
information regarding benefits, conditions, limitations, and exclusions.
The document(s) accompanying this transmission may contain confidential health information. This information is intended only for the use of
the individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or
action taken in reliance on the contents of these documents is strictly prohibited. If you received this information in error, please notify the
sender immediately and arrange for the return or destruction of the documents.
Brand NSAID Step Therapy
4.1.2013
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