Express Scripts Prior Authorization Form - Arb Step Therapy
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1
2Prior Authorization Form
ARB Step Therapy
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-329-3760
applicable to all patients; certain plans and situations may require
additional information beyond what is specifically requested.
If this an URGENT request, please call 1-800-753-2851
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:
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Atacand 4mg
Cozaar 50mg
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Hyzaar 50mg-12.5mg
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Atacand 8mg
Cozaar 100mg
Hyzaar 100mg-12.5mg
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Atacand 16mg
Diovan 40mg
Hyzaar 100mg-25mg
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Atacand 32mg
Diovan 80mg
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Micardis HCT 40mg-12.5mg
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Atacand HCT 16mg-12.5mg
Diovan 160mg
Micardis HCT 80mg-12.5mg
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Atacand HCT 32mg-12.5mg
Diovan 320mg
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Micardis HCT 80mg-25mg
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Atacand HCT 32mg-25mg
Diovan HCT 80mg-12.5mg
Micardis 20mg
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Avalide 150mg-12.5mg
Diovan HCT 160mg-12.5mg
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Micardis 40mg
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Avalide 300mg-12.5mg
Diovan HCT 160mg-25mg
Micardis 80mg
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Avalide 300mg-25mg
Diovan HCT 320mg-12.5mg
Teveten 400mg
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Avapro 75mg
Diovan HCT 320mg-25mg
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Teveten 600mg
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Avapro 150mg
Edarbi 40mg
Teveten HCT 600mg-12.5mg
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Avapro 300mg
Edarbi 80mg
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Teveten HCT 600mg-25mg
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Azor 5mg-20mg
Edarbyclor 40mg-12.5mg
Tribenzor 20mg-5mg-12.5mg
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Azor 5mg-40mg
Edarbyclor 40mg-25mg
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Tribenzor 40mg-5mg-12.5mg
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Azor 10mg-20mg
Exforge 5mg-160mg
Tribenzor 40mg-5mg-25mg
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Azor 10mg-40mg
Exforge 5mg-320mg
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Tribenzor 40mg-10mg-12.5mg
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Benicar 5mg
Exforge 10mg-160mg
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Tribenzor 40mg-10mg-25mg
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Benicar 20mg
Exforge 10mg-320mg
Twynsta 40mg-5mg
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Benicar 40mg
Exforge HCT 5mg-160mg-12.5mg
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Twynsta 40mg-10mg
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Benicar HCT 20mg-12.5mg
Exforge HCT 5mg-160mg-25mg
Twynsta 80mg-5mg
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Benicar HCT 40mg-12.5mg
Exforge HCT 10mg-160mg-12.5mg
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Twynsta 80mg-10mg
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Benicar HCT 40mg-25mg
Exforge HCT 10mg-160mg-25mg
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Exforge HCT 10mg-320mg-25mg
Directions for use (i.e. QD, BID, PRN & Qty): ________________________________________________________________________
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Please complete the clinical assessment:
Yes
No
1. Is the patient currently taking the A-II antagonist (ARB) or A-II antagonist (ARB) combination product being
requested?
If yes, how long has the patient been taking the medication? _____________________________________
ARB Step Therapy: F-14
4.2.2013
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