Form Frx013 - Prior Authorization Request Form For Multiple Sclerosis Betaseron/copaxone/rebif

FORM # FRX013

Prior Authorization Request Form for Multiple Sclerosis

Betaseron/Copaxone/Rebif

Member Information

Provider Information

Patient Name ____________________________

Provider Name _____________________________

Cardholder ID ___________________________

DEA Number ______________________________

Date of Birth ____________________________

Address ___________________________________

Address ________________________________

City, State and Zip ___________________________

City, State Zip ___________________________

Phone Number ______________________________

Phone Number ___________________________

FAX Number _______________________________

Pharmacy Information

Pharmacy Name___________________Address__________________Phone______________________

Criteria for Approval:

1. MS product requested: Check one:

Betaseron

Copaxone

Rebif

2. Does the patient have a diagnosis of primary progressive multiple sclerosis? Yes

No

3. Does the patient have a diagnosis of:

Check one:

Secondary progressive multiple sclerosis

Relapsing-remitting multiple sclerosis

4. Is this a new medication therapy or a continuation therapy:

Check one:

New

Continuation – Start Date: __________________

5. Is this the first clinical episode of multiple sclerosis for this patient?

Yes

No

6. Did the patient receive a magnetic resonance imaging (MRI) scan that showed features consistent with a

diagnosis of multiple sclerosis?

Yes

No

Provider Signature _________________________________________ Date ________________________

Fax completed forms to (866) 284-4509.

For Office Use Only

Date/TimeReceived_____________________________________________________________________

ReferenceNumber_______________________________________________________________________

Approved / Denied (Circle One) by _____________________________Date________________________

Date/Time Returned to Provider___________________________________________________________

_____________________________________________________________________________________

If you have any questions regarding this form, contact the Prior Authorization Department Toll Free at

(866) 284-4492 or Fax Toll Free at (866) 284-4509.

FOX Rx Care Utilization Management

3375-I Capital Circle NE

Tallahassee, FL 32308

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