Ambetter Prior Authorization Form - Gattex

Send To:

AcariaHealth



Specialty Pharmacy Provider:________________



Date: ___________ Date Medication Required:____________

Ship to:

Physician

Patient’s Home

Other __________







Prior Authorization Form

Gattex

Patient Name: ___________________________________________________

Physician Name: _______________________________________________

Address: _______________________________________________________

State Lic #______________________ DEA # ________________________

City: ________________________________State: _______Zip:____________

NPI # _________________________ Specialty: _____________________

Home Phone: (___________) ___________ - _________________________

Practice Name/Hospital: _________________________________________

Work Phone: (_______) _____________ - _________________________

Address: _____________________________________________________

Cell Phone: (__________) _____________ - _________________________

City: __________________________ State: ________ Zip: ____________

Patient Soc. Sec #: _________________ Allergies:_______________________

Physician’s Ph: (__________) ____________ - ______________________

Date of Birth: ___/___/___ Sex:  Male Female

Weight _____ 

Physician’s Fax: (__________) ____________ - _____________________

lbs

kg



Height: _______ BSA: ________ m²

See attached demographic sheet

Nurse/Key Office Contact: ________________________________________

INSURANCE INFORMATION (Complete or Attach Copies of cards)

Primary Insurance:__________________

Secondary Insurance:________________

Rx Card (PBM):_____________________

Cardholder First Name: ______________

City:______________State:___________

City:______________State:___________

PBM BIN: ________________________

Last Name: _______________________

Plan #: ___________________________

Plan #: ___________________________

City:______________State:___________

Employer: ________________________

Group #: _________________________

Group #: _________________________

Group #: _________________________

ID #: ____________________________

Phone: (______) ________-__________

Phone: (______) ________-__________

Phone: (______) ________-__________

Group #: _________________________

DIAGNOSIS (Required)

Short Bowel Syndrome

Other: ___________________________





What is the ICD9 / ICD10 code? ________________________

PATIENT EVALUATION

1.

Has the patient required parenteral support for at least 12 months?  Yes  No

2.

Has the patient had an inadequate response
or intolerance/contraindication to any of the following?

Indicate all that apply or mark "None of the above"

 An antimotility agent (e.g. loperamide [Imodium], diphenoxylate/atropine [Lomotil])

 An antisecretory agent (i.e. PPI, H

blocker, octreotide [Sandostatin])

2

 A growth hormone product (e.g. Zorbtive)

 None of the above

3.

Is the patient currently receiving Gattex therapy?  Yes  No If No, no further questions

4.

Has the patient’s requirement for parenteral support decreased from baseline while on Gattex therapy?  Yes  No

**NOTE: We can NOT make a decision without a copy of pertinent lab results and/or the current clinical progress notes - Thank You**

MEDICATION

STRENGTH

DIRECTIONS

QUANTITY

REFILLS

Gattex



Physician’s Signature: ____________________________________

Date____/_____/____

 DAW (Dispense as Written)

IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the name addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under

applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to

disposal of the transmitted material. In no event should such material be read or retained by anyone other than the name addressee, except by express authority of sender to the name addressee.