Express Scripts Prior Authorization Form - Sedative Hypnotic Step Therapy
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1
2Prior Authorization Form
Sedative Hypnotic 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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Ambien 5mg
Edluar 10mg Sublingual Tablet
Silenor 3mg
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□
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Ambien 10mg
Lunesta 1mg
Silenor 6mg
□
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Ambien CR 6.25mg
Lunesta 2mg
Sonata 5mg
□
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Ambien CR 12.5mg
Lunesta 3mg
Sonata 10mg
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Edluar 5mg Sublingual Tablet
Rozerem 8mg
Zolpimist 5mg/actuation Oral Spray
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Intermezzo
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Directions for use (i.e. QD, BID, PRN & Qty):________________________________________________________________________
Please complete the clinical assessment:
Yes
No
N/A
1. Is the patient currently taking the requested medication?
If yes, for how long? _______________________________________________________
________________________________________________________________________
Yes
No
N/A
2. Is the patient taking samples or paying 100% out of pocket for the medication being
requested?
If no, please indicate:
□
Requested medication covered under previous insurance plan
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Started medication in hospital
□
Other:
___________________________________________________________________
Yes
No
N/A
3. Does the patient have difficulty swallowing OR is the patient unable to swallow tablets?
Sedative Hypnotics Step Therapy: F-14
4.2.2013
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