"Medicare Part - D Actiq (Transmucosal Fentanyl Citrate) Prior Authorization of Benefits (Pab) Form - Express Scripts"

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To initiate your request immediately, please call the
Prior Authorization of Benefits Center at (800) 338-6180
To submit your request via fax, complete this form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
CONTAINS CONFIDENTIAL PATIENT INFORMATION
Medicare Part - D
Actiq (transmucosal fentanyl citrate)
Prior Authorization of Benefits (PAB) Form
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: _______________________________
Prescribing Physician: ___________________________
Patient ID #:
_______________________________
Physician Address:
___________________________
Patient DOB: ________________________________
Physician Phone #:
___________________________
Date of Rx:
________________________________
Physician Fax #:
___________________________
Patient Phone #: _____________________________
Physician Specialty:
___________________________
Physician DEA:
___________________________
Patient Email Address: _________________________
Physician NPI #:
___________________________
Physician Email Address: ________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
Actiq (fentanyl)
__________________
______________________
Specify: _________________
CHECK ALL BOXES THAT APPLY
7. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
What is the patient’s diagnosis? ______________________________________________________________________
What other medications has the patient tried for this diagnosis?
1. __________________________ Dates: ________________________ Outcome: ______________________________
2. __________________________ Dates: ________________________ Outcome: ______________________________
3. __________________________ Dates: ________________________ Outcome: ______________________________
Yes
No
Patient has previously tried and failed two formulary products: one of which is in the SAME specific
drug class; the other product can be in a DIFFERENT drug class; HOWEVER, it must have the
SAME indication as the product requested
Yes
No
Patient has a documented drug-drug interaction with formulary products
Yes
No
Patient has a documented drug-disease interaction with formulary products
If yes, please list the specific drug-drug or drug-disease interaction(s) below:
_______________________________________________________________________________
8. PHYSICIAN SIGNATURE
____________________________________________________________
__________________________________________
Prescriber or Authorized Signature
Date
Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what
medications are appropriate for a 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 that is legally privileged. This information is intended only
for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other
party unless required to do so by law or regulation.
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 have received this information in error, please notify the sender immediately and arrange for the return or
destruction of these documents.
Med D Actiq PAB Fax Form 01.11.16.doc
To initiate your request immediately, please call the
Prior Authorization of Benefits Center at (800) 338-6180
To submit your request via fax, complete this form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
CONTAINS CONFIDENTIAL PATIENT INFORMATION
Medicare Part - D
Actiq (transmucosal fentanyl citrate)
Prior Authorization of Benefits (PAB) Form
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: _______________________________
Prescribing Physician: ___________________________
Patient ID #:
_______________________________
Physician Address:
___________________________
Patient DOB: ________________________________
Physician Phone #:
___________________________
Date of Rx:
________________________________
Physician Fax #:
___________________________
Patient Phone #: _____________________________
Physician Specialty:
___________________________
Physician DEA:
___________________________
Patient Email Address: _________________________
Physician NPI #:
___________________________
Physician Email Address: ________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
Actiq (fentanyl)
__________________
______________________
Specify: _________________
CHECK ALL BOXES THAT APPLY
7. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
What is the patient’s diagnosis? ______________________________________________________________________
What other medications has the patient tried for this diagnosis?
1. __________________________ Dates: ________________________ Outcome: ______________________________
2. __________________________ Dates: ________________________ Outcome: ______________________________
3. __________________________ Dates: ________________________ Outcome: ______________________________
Yes
No
Patient has previously tried and failed two formulary products: one of which is in the SAME specific
drug class; the other product can be in a DIFFERENT drug class; HOWEVER, it must have the
SAME indication as the product requested
Yes
No
Patient has a documented drug-drug interaction with formulary products
Yes
No
Patient has a documented drug-disease interaction with formulary products
If yes, please list the specific drug-drug or drug-disease interaction(s) below:
_______________________________________________________________________________
8. PHYSICIAN SIGNATURE
____________________________________________________________
__________________________________________
Prescriber or Authorized Signature
Date
Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what
medications are appropriate for a 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 that is legally privileged. This information is intended only
for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other
party unless required to do so by law or regulation.
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 have received this information in error, please notify the sender immediately and arrange for the return or
destruction of these documents.
Med D Actiq PAB Fax Form 01.11.16.doc