Botox Passport - Prior Authorization Request Form printable pdf download

Botox

Passport - Prior Authorization Request

CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain

medications in order for the drug to be covered. To make an appropriate determination, providing the most accurate diagnosis for the use of the

prescribed medication is necessary. Please respond below and fax this form to CVS Caremark toll-free at 1-844-802-1404. If you have questions

regarding the prior authorization, please contact CVS Caremark at 1-844-380-8830. For inquiries or questions related to the patient’s eligibility, drug

copay or medication delivery; please contact the Specialty Customer Care Team: CaremarkConnect

1-800-237-2767.

Patient Name: _____________________________

Date: ________________________________

Patient’s ID: _______________________________

Patient’s Date of Birth: ________________

Physician’s Name: _______________________________________________________________________

Specialty: _________________________________

NPI#: ________________________________

Physician Office Telephone: __________________

Physician Office Fax: ___________________

1. What is the patient's diagnosis or reason for prescribing Botox?

 Cosmetic purposes

 Chronic migraine prophylaxis

 Cervical dystonia (e.g., spasmodic torticollis)

 Blepharospasm

 Strabismus

 Severe primary axillary hyperhidrosis inadequately managed by topical agent

 Excessive salivation secondary to Parkinson’s disease, multiple system atrophy, neurological disorders, bulbar

amyotrophic lateral sclerosis

 Lower limb spasticity from multiple sclerosis

 Cerebral palsy

 Bladder muscle dysfunction (overactive, neurologic)

 Incontinence due to spinal cord injury or trauma

 Spastic dysphonia

  Upper limb spasticity from cerebral vascular accident

  Upper limb spasticity from traumatic brain injury

  Lower limb spasticity from cerebral vascular accident or traumatic brain injury

  Abducens nerve palsy

  Achalasia

  Auriculotemporal syndrome (Frey’s syndrome)

  Fibromyalgia

  Hemifacial spasm

  Myofascial pain syndrome

  Oromandibular dystonia

 Other _____________________________________________

2. What is the ICD-10 code? ________________

3. Is this request for continuation of therapy?  Yes  No If No, skip to #5

4. Does the patient have the documented clinical benefits of Botox supporting continued treatment, OR Botox is being

continued in accordance with the recommended time as defined by FDA drug package insert, and/or per

recommendations of the medical compendium as described above, and/or per standard of care guidelines in each

respective disease state?  Yes  No

Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-844-802-1404

Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended

recipient you hereby are advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received the fax in error, please

immediately notify the sender by telephone and destroy the original fax message. Botox Passport - 9/2016.

CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062

Phone: 1-844-380-8830 ● Fax: 1-844-802-1404 ●

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