Sandostatin (Octreotide Acetate), Sandostatin Lar Depot (Octreotide Acetate) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Sandostatin (octreotide acetate),
Sandostatin LAR Depot (octreotide acetate)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: _______________________________
Prescribing Physician: ____________________________
Patient ID #:
_______________________________
Physician Specialty:
____________________________
Patient DOB: _______________________________
Physician Phone #:
_____________________________
Date of Rx:
_______________________________
Physician Fax #:
_____________________________
Patient Phone #: ____________________________
Physician Address:
_____________________________
Patient Email Address: ________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
□
Sandostatin (octreotide acetate)
□
____________
______________________
Specify: _________________
Sandostatin LAR Depot (octreotide
acetate)
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
□
□
Yes
No
Patient has a diagnosis of Acromegaly If Yes:
□
□
Yes
No
Patient has had an inadequate response to or cannot be treated with surgical
resection, pituitary irradiation, and bromocriptine mesylate at maximally
tolerated doses
□
□
Yes
No
Patient has metastatic carcinoid tumors
□
□
Yes
No
Patient has carcinoid syndrome to suppress or inhibit severe diarrhea and flushing episodes
associated with the disease
□
□
Yes
No
Patient has prophylactic administration prior to biopsy in an individual with a suspected functioning
carcinoid tumor
□
□
Yes
No
Patient has prophylactic administration prior to induction of anesthesia in an individual with a
functional carcinoid tumor
□
□
Yes
No
Patient has prophylactic administration perioperatively to a surgical procedure in an individual with a
functional carcinoid tumor
□
□
Yes
No
Patient has Neuroendocrine Tumors
If Yes:
□
□
Yes
No
Requested drug is being used for the management of unresectable locoregional
disease or distant metastasis
□
□
Yes
No
Requested drug is being used for treatment of the profuse watery diarrhea
associated with VIPomas
□
□
Yes
No
Requested drug is being for treatment of underlying Zollinger-Ellison syndrome
□
□
Yes
No
Requested drug is being used as prophylactic treatment prior to surgery for
gastrinoma
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CONTINUED ON PAGE 2
Sandostatin NTL PAB Fax Form 10.09.15.doc
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