Express Scripts Prior Authorization Form - Arb Step Therapy (Page 2 of 2) in pdf

 Yes

 No

2. Is the patient taking samples or paying 100% out of pocket for the medication being requested?

 Yes

 No

3. Has the patient tried one ACE inhibitor or ACE inhibitor combination product OR generic ARB or generic ARB

combination product?

: ____________________________________________________________

If yes, please list

 Yes

 No

4. Has the patient tried Azor, Tribenzor, Benicar, Benicar HCT, Exforge or Exforge HCT?

: ____________________________________________________________

If yes, please list

 Yes

 No

5. Was the patient recently hospitalized and discharged within the previous 30 days for a cardiovascular (CV)

event (e.g. myocardial infarction (MI), hypertensive emergency, decompensated heart failure) AND has been

started and stabilized on the requested medication?

: ___________________________

If yes, please document specific CV event and hospitalization date

 Yes

 No

6. Does the patient have heart failure AND has tried one ACE inhibitor or ACE inhibitor combination product OR

generic ARB or generic ARB combination product?

If yes, please list: __________________________________________________________________________

 Yes

 No

7. Does the patient have heart failure AND the generic equivalents of Atacand (candesartan) and Diovan

(valsartan) not available?

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.

ARB Step Therapy: F-14

4.2.2013

Express Scripts Prior Authorization Form - Arb Step Therapy Page 2

Related Articles

Related forms

Related Categories