Form F14 "Prior Authorization Form - Gabapentin Like Products Step Therapy - Express Scripts"

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Download Form F14 "Prior Authorization Form - Gabapentin Like Products Step Therapy - Express Scripts"

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Prior Authorization Form
Gabapentin Like Products 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:
Gralise 300mg
Lyrica 100mg
Neurontin 100mg
Gralise 600mg
Lyrica 150mg
Neurontin 300mg
Horizant 600mg
Lyrica 200mg
Neurontin 400mg
Lyrica 25mg
Lyrica 225mg
Neurontin 600mg
Lyrica 50mg
Lyrica 300mg
Neurontin 800mg
Lyrica 75mg
Neurontin 250mg/5ml Solution
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
 N/A
3. Has the patient had a trial of gabapentin immediate release or Neurontin?
 Yes
 No
 N/A
4. Has the patient had a trial of Horizant or Gralise?
F14
5.17.2013
Prior Authorization Form
Gabapentin Like Products 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:
Gralise 300mg
Lyrica 100mg
Neurontin 100mg
Gralise 600mg
Lyrica 150mg
Neurontin 300mg
Horizant 600mg
Lyrica 200mg
Neurontin 400mg
Lyrica 25mg
Lyrica 225mg
Neurontin 600mg
Lyrica 50mg
Lyrica 300mg
Neurontin 800mg
Lyrica 75mg
Neurontin 250mg/5ml Solution
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
 N/A
3. Has the patient had a trial of gabapentin immediate release or Neurontin?
 Yes
 No
 N/A
4. Has the patient had a trial of Horizant or Gralise?
F14
5.17.2013
 Yes
 No
 N/A
5. For the diagnosis of Generalized Anxiety Disorder (GAD), has the patient tried at least two of
the following: a TCA (e.g., imipramine, nortriptyline), an SSRI (e.g., paroxetine, Lexapro), an
SNRI (e.g., Effexor XR), or buspirone?
If yes, please list: ______________________________________________________________
_________________________________________________________________________________
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.
F14
5.17.2013
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