Prior Authorization Form
Antidepressant SNRI Step Therapy
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-800-357-9577
applicable to all patients; certain plans and situations may require
additional information beyond what is specifically requested.
If this an URGENT request, please call 1-800-417-8164
Additional forms available:
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:
□
Cymbalta 20mg
□
Pristiq 50mg Tablet
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Cymbalta 30mg
□
Pristiq 100mg Tablet
□
Cymbalta 60mg
□
Savella 12.5mg Tablet
□
Effexor 25mg Tablet
□
Savella 25mg Tablet
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Effexor 37.5mg Tablet
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Savella 50mg Tablet
□
Effexor 50mg Tablet
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Savella 100mg Tablet
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Effexor 75mg Tablet
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Savella Titration Pack
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Effexor 100mg Tablet
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Venlafaxine extended release tablet
(Upstate Pharma –brand product)
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Effexor XR 37.5mg Capsule
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Other: ____________________________________________
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Effexor XR 75mg Capsule
_________________________________________________
□
Effexor XR 150mg Capsule
Directions for use (i.e. QD, BID, PRN & Qty): _________________________________________________________________________
Please complete the clinical assessment:
Yes
No
1. Is the patient currently taking the requested medication?
If yes, how long has the patient been taking the requested medication? _____________________________
_______________________________________________________________________________________
Yes
No
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: ___________________________________________________________________