Proton Pump Inhibitors (Ppi) Prior Authorization Request Form (Page 2 of 2) in pdf

Proton Pump Inhibitors (PPI) Prior Authorization Request Form (Page 2 of 2)

DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

For Nexium suspension and Prevacid Solutab requests, also answer the following*:

 Yes  No Is the member unable to ingest a solid dosage form (e.g., an oral tablet or capsule) due to one of the following:

Age, oral/motor difficulties, or dysphagia?

 Yes  No Is the member utilizing a feeding tube for medication administration?

 Yes  No Does the member have a history of failure, contraindication, or intolerance to ALL of the following: A prescription formulation of

omeprazole, pantoprazole, and rabeprazole?

If yes, please list the reason for therapeutic failure, contraindication, or intolerance for each medication (if applicable):

Pantoprazole**

Reason:___________________________________________________________________

Prescription formulation of omeprazole**

Reason:___________________________________________________________________

Rabeprazole**

Reason:___________________________________________________________________

For Zegerid suspension requests, also answer the following*:

 Yes  No Is the member unable to ingest a solid dosage form (e.g., an oral tablet or capsule) due to one of the following:

Age, oral/motor difficulties, or dysphagia?

 Yes  No Is the member utilizing a feeding tube for medication administration?

Does the member have a history of failure, contraindication, or intolerance to the following?

 Yes  No Dexilant**

 Yes  No Pantoprazole (generic Protonix)**

 Yes  No Nexium suspension**

 Yes  No Prevacid Solutab**

 Yes  No Omeprazole (generic Prilosec)**

 Yes  No Rabeprazole (generic Aciphex)**

*May not apply to all plans

** This product may require prior authorization

Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to

this review?

________________________________________________________________________________________________________________

Please note:

This request may be denied unless all required information is received.

For urgent or expedited requests please call 1-800-711-4555.

This form may be used for non-urgent requests and faxed to 1-800-527-0531.

______________________________________________________________________________________________________________

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider

named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose

PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information

in this document is against the law. If you are not the intended recipient, please notify the sender immediately.

Office use only: ProtonPumpInhibitors_UHCE&I_2016Jul-W.doc