Zithromax (Azithromycin) Quantity Supply Prior Authorization Of Benefits (Pab) Form
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2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Zithromax (azithromycin) Quantity Supply
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 Address:
_____________________________
Patient DOB: __________________________________
Physician Phone #:
_____________________________
Date of Rx:
__________________________________
Physician Fax #:
_____________________________
Patient Phone #: _______________________________
Physician Specialty:
____________________________
Patient Email Address: ___________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY
□
250mg Tablets
□
250mg ZPak Tablets
□
500mg Tablets
□
500mg TriPak Tablets
□
Zithromax (azithromycin)
___________________
Specify: _____________
600mg Tablets
□
1gm Suspension
□
ZMax 2g Suspension ER
□
100mg/5mL Suspension
□
200mg/5mL Suspension
CHECK ALL BOXES THAT APPLY
7. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
Please indicate the patient’s diagnosis:
□
Mild to moderate infections caused by Campylobacter jejuni
□
Babesiosis
□
Mycobacterium avium complex (MAC)
□
Chronic sinusitis
□
Pelvic inflammatory disease
□
Cystic fibrosis (CF)
□
Pharyngitis
□
Gonorrhea
□
Pneumonia requiring initial IV therapy
□
HIV/AIDS AND cryptosporidiosis (Cryptosporidium
□
Strep Throat
parvum)
□
□
Tonsilitis
HIV AND Bartonella
□
□
Toxoplasmosis caused by Toxoplasma gondii
Legionnaires’ disease
□
□
Other: _______________________________________
Lyme disease (Borrelia burgdorferi infections)
Please indicate patient’s weight: _________kg
□
□
Yes
No
Patient is 16 years of age or older
For Babesiosis:
Diagnosis was confirmed by:
□
□
□
positive blood smear
positive Polymerase Chain Reaction (PCR)
titer of at least 1:256
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Zithromax Quantity Supply NTL PAB Fax Form 02.05.15.doc
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