"Vivitrol (Naltrexone Extended Release-Injectable) Prior Authorization of Benefits (Pab) Form - Express Scripts"

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CONTAINS CONFIDENTIAL PATIENT INFORMATION
Vivitrol (naltrexone extended release-injectable)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Prescribing Physician: ____________________________
Patient Name: __________________________________
Physician Address:
_____________________________
Patient ID #:
__________________________________
Physician Phone #:
_____________________________
Patient DOB: __________________________________
Physician Fax #:
_____________________________
Date of Rx:
__________________________________
Physician Specialty:
____________________________
Patient Phone #: _______________________________
Physician DEA:
____________________________
Patient Email Address: ___________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
Vivitrol (naltrexone extended
______________________
_______________________
380mg/vial
release-injectable)
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
Treatment of alcohol dependence:
Yes
No Patient is being treated for alcohol dependence
Yes
No Patient has abstained from alcohol for at least 7 days in an outpatient setting prior to treatment initiation
Yes
No Patient has had an initial response and tolerates oral naltrexone (Revia)
Yes
No Patient is able to comply with daily dosing
Yes
No Patient is actively drinking during time of initial Vivitrol administration
Yes
No Patient actively participates in a comprehensive rehabilitation program that includes psychosocial
support
Treatment of opioid dependence:
Yes
No Patient is using Vivitrol to prevent relapse of opioid dependence
Yes
No Patient is being treated for opioid dependence
Yes
No Patient has successfully completed an opioid detoxification program
Yes
No Patient has had an initial response and tolerates oral naltrexone (Revia)
Yes
No Patient is unable to comply with daily dosing
Yes
No Patient has been opioid-free (including buprenorphine and methadone) for at least 7 days prior to
treatment initiation
Yes
No Patient actively participates in a comprehensive rehabilitation program that includes psychosocial
support
A RESPONSE IS REQUIRED FOR EACH OF THE FOLLOWING:
Yes
No Patient is currently on opioid analgesics for pain management
Yes
No Patient is currently physiologically dependent on opioids
Yes
No Patient is currently in acute opioid withdrawal
Yes
No Patient failed the naloxone challenge test
PAGE 1 OF 2
Vivitrol NTL PAB Fax Form 4.13.11.doc
CONTINUED ON PAGE 2
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
CONTAINS CONFIDENTIAL PATIENT INFORMATION
Vivitrol (naltrexone extended release-injectable)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Prescribing Physician: ____________________________
Patient Name: __________________________________
Physician Address:
_____________________________
Patient ID #:
__________________________________
Physician Phone #:
_____________________________
Patient DOB: __________________________________
Physician Fax #:
_____________________________
Date of Rx:
__________________________________
Physician Specialty:
____________________________
Patient Phone #: _______________________________
Physician DEA:
____________________________
Patient Email Address: ___________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
Vivitrol (naltrexone extended
______________________
_______________________
380mg/vial
release-injectable)
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
Treatment of alcohol dependence:
Yes
No Patient is being treated for alcohol dependence
Yes
No Patient has abstained from alcohol for at least 7 days in an outpatient setting prior to treatment initiation
Yes
No Patient has had an initial response and tolerates oral naltrexone (Revia)
Yes
No Patient is able to comply with daily dosing
Yes
No Patient is actively drinking during time of initial Vivitrol administration
Yes
No Patient actively participates in a comprehensive rehabilitation program that includes psychosocial
support
Treatment of opioid dependence:
Yes
No Patient is using Vivitrol to prevent relapse of opioid dependence
Yes
No Patient is being treated for opioid dependence
Yes
No Patient has successfully completed an opioid detoxification program
Yes
No Patient has had an initial response and tolerates oral naltrexone (Revia)
Yes
No Patient is unable to comply with daily dosing
Yes
No Patient has been opioid-free (including buprenorphine and methadone) for at least 7 days prior to
treatment initiation
Yes
No Patient actively participates in a comprehensive rehabilitation program that includes psychosocial
support
A RESPONSE IS REQUIRED FOR EACH OF THE FOLLOWING:
Yes
No Patient is currently on opioid analgesics for pain management
Yes
No Patient is currently physiologically dependent on opioids
Yes
No Patient is currently in acute opioid withdrawal
Yes
No Patient failed the naloxone challenge test
PAGE 1 OF 2
Vivitrol NTL PAB Fax Form 4.13.11.doc
CONTINUED ON PAGE 2
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
CONTAINS CONFIDENTIAL PATIENT INFORMATION
Vivitrol (naltrexone extended release-injectable)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
Patient Name: ___________________________________
Patient ID#: __________________________________
Yes
No Patient had a positive urine screen for opioids
Yes
No Patient has acute hepatitis
Yes
No Patient has liver failure
Yes
No Patient had a previous hypersensitivity to naltrexone, 75:25 polyactide-co-glycolide (PLG),
carboxymethylcellulose or any other component of the diluent
9. 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 submitting
provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.
Note: Payment is subject to member eligibility. Authorization does not guarantee payment.
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.
PAGE 2 OF 2
Vivitrol NTL PAB Fax Form 4.13.11.doc
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
Page of 2