Form Frx0025 - Prior Authorization Request Form For Lotronex (Alosetron)
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2FORM # FRX0025
Prior Authorization Request Form for Lotronex (alosetron)
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______________________
FDA Approved Indications:
• The treatment of Irritable Bowel Syndrome (IBS) in women with severe diarrhea – predominant symptoms
who have failed to respond to conventional therapy, whose symptoms are chronic (generally lasting longer
than six months), and who have had other gastrointestinal medical conditions ruled out.
• The safety and effectiveness of Lotronex in men has not been established.
Criteria for Approval:
1. Is the patient 18 years of age or older?
Yes
No
2. Is the patient female?
Yes
No
3. Does the patient have a diagnosis of diarrhea-predominant chronic irritable bowel syndrome (IBS)? Yes
No
4. Has the physician excluded anatomical or biochemical abnormalities of the gastrointestinal tract
(i.e., thyroid dysfunction, stool culture, colonoscopy, barium enema)?
Yes
No
5. Has the patient had continuous or recurrent symptoms of irritable bowel syndrome (IBS)
for at least 6 months?
Yes
No
6. Has the patient experienced therapeutic failure with any of the following? Check all that apply:
Dicyclomine
Hyoscyamine
Loperamide
Diphenoxylate/atropine
Fiber supplement
Other: ____________
7. Does the patient have any of the following: Check all that apply:
iarrhea-prominent disease
D
Frequent and severe abdominal pain and discomfort
Frequent bowel urgency and/or fecal incontinence
Disability or restriction of daily activities due to irritable bowel syndrome (IBS)
8. Does the patient have a history of any of the following? Check all that apply:
Severe constipation or sequelae from constipation
Intestinal obstruction, stricture, toxic megacolon, gastrointestinal perforation, and/or adhesions
Ischemic colitis, impaired intestinal circulation, thrombophlebitis, or hypercoagulable state
Crohn’s disease or ulcerative colitis
Diverticulitis
9. Does the patient have any known hypersensitivity to any componenet of Lotronex?
Yes
No
10. Has the physician counseled the patient about known risks versus benefits of using Lotronex
to treat irritable bowel syndrome (IBS)?
Yes
No
11. Will the patient be monitored for adverse events associated with using Lotronex
(i.e., constipation or ischemic colitis)?
Yes
No
12. Is the physician enrolled in the Lotronex Prescribing Program?
Yes
No
13. Has the patient received and completed the Lotronex Medication Guide?
Yes
No
14. Have both the patient and physician signed the Patient-Physician Agreement?
Yes
No
15. If the patient has received previous Lotronex therapy, has there been improvement of
irritable bowel symptoms?
Yes
No
16. Is this request for an increase in the dose of Lotronex?
Yes
No
17. Does the patient require more than 2 tablets (2 mg) per day?
Yes
No
Provider Signature ___________________________________Date_____________________
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