Express Scripts Prior Authorization Form - Hmg Step Therapy Page 2

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 Yes
 No
3. Has the patient tried any of the following?
atorvastatin (generic)
Crestor
lovastatin (generic)
Lipitor (Brand)
pravastatin (generic)
Vytorin
simvastatin (generic)
Mevacor (Brand)
fluvastatin (generic)
Pravachol (Brand)
Zocor (Brand)
amlodipine/atorvastatin (generic)
Caduet (Brand)
Other: _____________________________
___________________________________
: ________________________________________________
If no, please explain
______________________________________________________________
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.
HMG Step Therapy: F-14
4.2.2013

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