Express Scripts Prior Authorization Form - Brand Nsaid Step Therapy (Page 2 of 2) in pdf

 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

3. Has the patient tried two unique prescription-strength generic NSAIDs for the current

condition?

: _________________________

If yes, please provide names, strengths and directions

______________________________________________________________

 Yes

 No

 N/A

4. If prescribing Flector Patch, Sprix, Pennsaid, or Voltaren Gel only, is the patient unable to or has

difficulty swallowing?

 Yes

 No

 N/A

5. If prescribing Pennsaid or Voltaren Gel only, does the patient have a chronic musculoskeletal

pain condition (e.g., osteoarthritis)?

If yes, please document: _________________________________________________________

6. If prescribing Pennsaid or Voltaren Gel only, how many joints or sites is the requested medication being applied to?

Please list: __________________________________________________________________________________________________

 Yes

 No

 N/A

7. If prescribing Pennsaid or Voltaren Gel only, is the patient at risk of NSAID-associated toxicity?

If yes, what NSAID associated toxicity is the patient at risk for? _________________________

____________________________________________________________________________

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.

Brand NSAID Step Therapy

4.1.2013

Express Scripts Prior Authorization Form - Brand Nsaid Step Therapy Page 2

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