Prior Authorization Form Antidepressant Snri Step Therapy

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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
Cymbalta 30mg
Pristiq 100mg Tablet
Cymbalta 60mg
Savella 12.5mg Tablet
Effexor 25mg Tablet
Savella 25mg Tablet
Effexor 37.5mg Tablet
Savella 50mg Tablet
Effexor 50mg Tablet
Savella 100mg Tablet
Effexor 75mg Tablet
Savella Titration Pack
Effexor 100mg Tablet
Venlafaxine extended release tablet
(Upstate Pharma –brand product)
Effexor XR 37.5mg Capsule
Other: ____________________________________________
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: ___________________________________________________________________

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