Form P-23154 - Synvisc Orthovisc Hyalgan Supartz Euflexxa Authorization Form

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Clear Form

Synvisc

Orthovisc

Hyalgan

Supartz

Euflexxa

(hyaluronan)

Treatment Request (Physician to Complete)

Visit

for the Wellmark Drug List for

current medication tier levels and updated PA Forms

Facsimile Transmittal Sheet

Date: ____/____/____

To: Wellmark Pharmacy Services

From (Prescriber’s Name):

Fax Number:

(866) 884-4345

Prescriber’s DEA Number:

Phone Number:

(800) 600-8065

Prescriber’s Phone Number:

Prescriber’s Specialty:

Prescriber’s Fax Number:

Prescriber’s Office Address:

Street

Suite #

City

State

Zip

Patient Name:

Patient ID:

Patient DOB: __________/___________/____________

Please answer the following questions and fax this form back to (866) 884-4345. All fields are REQUIRED.

1. Please provide the diagnosis this therapy has been prescribed for:

ICD-9 Code:

2. Please list all pharmacological therapies tried for this diagnosis and reason(s) for discontinuation:

3. Please list any non-pharmacological therapies tried for this diagnosis:

4. Please select the requested medication

Synvisc

Orthovisc

Hyalgan

Supartz

Euflexxa

5. Dose per injection:

Frequency of injection:

per

6. Please list the dates of previous treatment courses?______________________________________________

7. Did the patient experience significant pain relief with prior treatment course?_________________________________

Attach lab results and other documentation as necessary

Printed Name

Signature

Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the

intended recipient, you hereby are advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received this

fax in error, please immediately notify the sender by telephone and destroy this original fax message.

P-23154 12/08