Form F14 "Prior Authorization Form - Arb Step Therapy - Express Scripts"

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Download Form F14 "Prior Authorization Form - Arb Step Therapy - Express Scripts"

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Prior Authorization Form
ARB Step Therapy
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-329-3760
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:
Atacand 4mg
Cozaar 50mg
Hyzaar 50mg-12.5mg
Atacand 8mg
Cozaar 100mg
Hyzaar 100mg-12.5mg
Atacand 16mg
Diovan 40mg
Hyzaar 100mg-25mg
Atacand 32mg
Diovan 80mg
Micardis HCT 40mg-12.5mg
Atacand HCT 16mg-12.5mg
Diovan 160mg
Micardis HCT 80mg-12.5mg
Atacand HCT 32mg-12.5mg
Diovan 320mg
Micardis HCT 80mg-25mg
Atacand HCT 32mg-25mg
Diovan HCT 80mg-12.5mg
Micardis 20mg
Avalide 150mg-12.5mg
Diovan HCT 160mg-12.5mg
Micardis 40mg
Avalide 300mg-12.5mg
Diovan HCT 160mg-25mg
Micardis 80mg
Avalide 300mg-25mg
Diovan HCT 320mg-12.5mg
Teveten 400mg
Avapro 75mg
Diovan HCT 320mg-25mg
Teveten 600mg
Avapro 150mg
Edarbi 40mg
Teveten HCT 600mg-12.5mg
Avapro 300mg
Edarbi 80mg
Teveten HCT 600mg-25mg
Azor 5mg-20mg
Edarbyclor 40mg-12.5mg
Tribenzor 20mg-5mg-12.5mg
Azor 5mg-40mg
Edarbyclor 40mg-25mg
Tribenzor 40mg-5mg-12.5mg
Azor 10mg-20mg
Exforge 5mg-160mg
Tribenzor 40mg-5mg-25mg
Azor 10mg-40mg
Exforge 5mg-320mg
Tribenzor 40mg-10mg-12.5mg
Benicar 5mg
Exforge 10mg-160mg
Tribenzor 40mg-10mg-25mg
Benicar 20mg
Exforge 10mg-320mg
Twynsta 40mg-5mg
Benicar 40mg
Exforge HCT 5mg-160mg-12.5mg
Twynsta 40mg-10mg
Benicar HCT 20mg-12.5mg
Exforge HCT 5mg-160mg-25mg
Twynsta 80mg-5mg
Benicar HCT 40mg-12.5mg
Exforge HCT 10mg-160mg-12.5mg
Twynsta 80mg-10mg
Benicar HCT 40mg-25mg
Exforge HCT 10mg-160mg-25mg
Exforge HCT 10mg-320mg-25mg
Directions for use (i.e. QD, BID, PRN & Qty): ________________________________________________________________________
Please complete the clinical assessment:
 Yes
 No
1. Is the patient currently taking the A-II antagonist (ARB) or A-II antagonist (ARB) combination product being
requested?
If yes, how long has the patient been taking the medication? _____________________________________
ARB Step Therapy: F-14
4.2.2013
Prior Authorization Form
ARB Step Therapy
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-329-3760
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:
Atacand 4mg
Cozaar 50mg
Hyzaar 50mg-12.5mg
Atacand 8mg
Cozaar 100mg
Hyzaar 100mg-12.5mg
Atacand 16mg
Diovan 40mg
Hyzaar 100mg-25mg
Atacand 32mg
Diovan 80mg
Micardis HCT 40mg-12.5mg
Atacand HCT 16mg-12.5mg
Diovan 160mg
Micardis HCT 80mg-12.5mg
Atacand HCT 32mg-12.5mg
Diovan 320mg
Micardis HCT 80mg-25mg
Atacand HCT 32mg-25mg
Diovan HCT 80mg-12.5mg
Micardis 20mg
Avalide 150mg-12.5mg
Diovan HCT 160mg-12.5mg
Micardis 40mg
Avalide 300mg-12.5mg
Diovan HCT 160mg-25mg
Micardis 80mg
Avalide 300mg-25mg
Diovan HCT 320mg-12.5mg
Teveten 400mg
Avapro 75mg
Diovan HCT 320mg-25mg
Teveten 600mg
Avapro 150mg
Edarbi 40mg
Teveten HCT 600mg-12.5mg
Avapro 300mg
Edarbi 80mg
Teveten HCT 600mg-25mg
Azor 5mg-20mg
Edarbyclor 40mg-12.5mg
Tribenzor 20mg-5mg-12.5mg
Azor 5mg-40mg
Edarbyclor 40mg-25mg
Tribenzor 40mg-5mg-12.5mg
Azor 10mg-20mg
Exforge 5mg-160mg
Tribenzor 40mg-5mg-25mg
Azor 10mg-40mg
Exforge 5mg-320mg
Tribenzor 40mg-10mg-12.5mg
Benicar 5mg
Exforge 10mg-160mg
Tribenzor 40mg-10mg-25mg
Benicar 20mg
Exforge 10mg-320mg
Twynsta 40mg-5mg
Benicar 40mg
Exforge HCT 5mg-160mg-12.5mg
Twynsta 40mg-10mg
Benicar HCT 20mg-12.5mg
Exforge HCT 5mg-160mg-25mg
Twynsta 80mg-5mg
Benicar HCT 40mg-12.5mg
Exforge HCT 10mg-160mg-12.5mg
Twynsta 80mg-10mg
Benicar HCT 40mg-25mg
Exforge HCT 10mg-160mg-25mg
Exforge HCT 10mg-320mg-25mg
Directions for use (i.e. QD, BID, PRN & Qty): ________________________________________________________________________
Please complete the clinical assessment:
 Yes
 No
1. Is the patient currently taking the A-II antagonist (ARB) or A-II antagonist (ARB) combination product being
requested?
If yes, how long has the patient been taking the medication? _____________________________________
ARB Step Therapy: F-14
4.2.2013
 Yes
 No
2. Is the patient taking samples or paying 100% out of pocket for the medication being requested?
 Yes
 No
3. Has the patient tried one ACE inhibitor or ACE inhibitor combination product OR generic ARB or generic ARB
combination product?
: ____________________________________________________________
If yes, please list
 Yes
 No
4. Has the patient tried Azor, Tribenzor, Benicar, Benicar HCT, Exforge or Exforge HCT?
: ____________________________________________________________
If yes, please list
 Yes
 No
5. Was the patient recently hospitalized and discharged within the previous 30 days for a cardiovascular (CV)
event (e.g. myocardial infarction (MI), hypertensive emergency, decompensated heart failure) AND has been
started and stabilized on the requested medication?
: ___________________________
If yes, please document specific CV event and hospitalization date
 Yes
 No
6. Does the patient have heart failure AND has tried one ACE inhibitor or ACE inhibitor combination product OR
generic ARB or generic ARB combination product?
If yes, please list: __________________________________________________________________________
 Yes
 No
7. Does the patient have heart failure AND the generic equivalents of Atacand (candesartan) and Diovan
(valsartan) not available?
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.
ARB Step Therapy: F-14
4.2.2013
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