Prior Authorization Form - Vyvanse-Intuniv-Daytra

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Prior Authorization Form
Lipitor®/Caduet®/Vytorin®*/Crestor®*
ONLY COMPLETED REQUESTS WILL BE REVIEWED
Drug Requested: (check one)
Lipitor®
Caduet®
Vytorin®*
Crestor®* #
Date: __________________________
Patient ID#: ________________ DOB:___________
Patient Name: _______________________________
Provider NPI: _______________________________
Prescribing Physician: _________________________
Office Contact: ______________________________
Office Fax #: _______________________________
Office Phone: _______________________________
ONLY COMPLETED REQUESTS WILL BE REVIEWED
1. DIAGNOSIS FOR DRUG REQUESTED: ________________________________________
2. MEDICATION HISTORY
(Please list any previous or current therapy related to the diagnosis, using drug names and dates)
N/A
If none or not applicable to diagnosis, indicate “N/A.”
Drug Name
Date
Duration
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
3. PATIENT HISTORY
:
a. Has the patient tried and failed a Simvastatin containing product for a minimum of 30 days?
Yes
No
b. Has the patient tried and failed a Pravastatin containing product for a minimum of 30 days?
Yes
No
c. Has the patient tried and failed a Lovastatin containing product for a minimum of 30 days?
Yes
No
d. Has the patient tried and failed a rosuvastatin calcium (Crestor®) for a minimum of 30
Yes
No
days?
e. Does the patient have an intolerance/contraindication/allergy to Simvastatin, Pravastatin,
Lovastatin containing product or Crestor®? (please specify in the supporting information
section)
Yes
No
Please add any other supporting medical information that may be useful in the decision-making process:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
(888) 671-5285
FAX TO
. YOUR OFFICE WILL RECEIVE A RESPONSE VIA FAX OR MAIL.
Internal use only
Coverage effective date
/
/
Document #__________________________
Processor Initials___________
Date____________________
M
F
Rx coverage
Y
N
STANDARD - SELECT
LOB____________________
Previous Auth
Y
N
Approved
Reviewer Initials_____________
Date_____________
* CRESTOR AND VYTORIN DO NOT REQUIRE PRIOR AUTHORIZATION UNDER MEDICARE PART D
01/2010 PA014-LIP-CAD-VYT-CREST
Provider Communication
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield.
Independent licensees of the Blue Cross and Blue Shield Association

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