Livalo (Pitavastatin) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Livalo (pitavastatin)
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
Prescribing Physician: ____________________________
Patient Name: __________________________________
Physician Address:
_____________________________
Patient ID #:
__________________________________
Physician Phone #:
_____________________________
Patient DOB: __________________________________
Physician Fax #:
_____________________________
Date of Rx:
__________________________________
Physician Specialty:
____________________________
Patient Phone #: _______________________________
Physician DEA:
____________________________
Patient Email Address: ___________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
_________
Livalo (pitavastatin)
____ ____________________ ____________________
7. DIAGNOSIS: _____________________________________________________________________________________
8. CLINICAL INFORMATION
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of
this request
List trial of statins (excluding samples) - Please include the following information:
TRIAL DATE(s)
DRUG NAME
DOSE
SIG
OUTCOME
AND DURATION
1.
2.
3.
9. APPROVAL CRITERIA: CHECK ALL BOXES THAT APPLY
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of
this request
□
□
Yes
No
Patient has had at least a 90 day trial of a generic statin and failed to achieve LDL cholesterol goal
(Please provide documentation)
Documentation for all cholesterol lowering medications tried and failed MUST be provided:
Should include, but is not limited to, chart notes, prescription claims records, prescription receipts,
laboratory data, reason for failure of medications tried (e.g. symptoms, frequency)
□
□
Yes
No
Patient has had at least a 90 day trial of one preferred branded statin (Crestor) and failed to achieve LDL
cholesterol goal (Please provide documentation)
Documentation for all cholesterol lowering medications tried and failed MUST be provided:
Should include, but is not limited to, chart notes, prescription claims records, prescription receipts,
laboratory data, reason for failure of medications tried (e.g. symptoms, frequency)
□
□
Yes
No
Patient has had a trial of one preferred generic or one preferred brand statin drug in the previous 180 days
and documentation of an adverse event or clinically relevant intolerance due to therapy is provided.
[Preferred brand statins: Crestor; Preferred generic statins: atorvastatin (generic Lipitor), fluvastatin
(generic Lescol), fluvastatin ER (generic Lescol XL), lovastatin (generic Mevacor), pravastatin (generic
pravachol), simvastatin (generic Zocor)
(Please provide documentation)
Documentation MUST be provided: Should include, but is not limited to, chart notes, prescription claims
records, prescription receipts, laboratory data, reason for failure of medications tried (e.g. symptoms,
frequency)
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Livalo NTL PAB Fax Form 12.12.15.doc
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