Prior Authorization Form Antidepressant Snri Step Therapy (Page 2 of 2) in pdf

3. What is the indication or diagnosis?

□

Chronic musculoskeletal pain (for example: chronic low back pain or chronic osteoarthritis pain)

□

Depression

□

Fibromyalgia

□

Stress urinary incontinence (SUI) in women or men

□

All other indications, please list: ___________________________________________________________________________

 Yes

 No

4. Was the patient on the requested drug on a previous occasion?

 Yes

 No

5. Is the patient suicidal?

 Yes

 No

6. Has the patient previously tried one SSRI (brand or generic) or venlafaxine immediate-release (brand or generic)

or venlafaxine extended release capsules or tablets (brand or generic); if so, which drug?

□

Citalopram (Celexa)

Pexeva

□

Fluoxetine (Prozac)

Prozac Weekly

□

Fluvoxamine (Luvox)

Sarafem

□

Lexapro

Sertraline (Zoloft)

□

Luvox CR

Venlafaxine extended release capsules or tablets

□

Paroxetine (Paxil)

(brand or generic)

□

Paxil CR

Other: __________________________________

 Yes

 No

7. If requesting Savella only, does the patient have depression and has tried at least two other agents for

treatment of depression (eg. SSRIs, SNRIs, TCAs, bupropion)?

If yes, please list other medications patient has tried for depression: _____________________________

____________________________________________________________________________________________

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.

Antidepressant SNRI Step Therapy

12.28.2011