Medicare Part - D Transmucosal Fentanyl Citrate Prior Authorization Of Benefits (Pab) Form

To initiate your request immediately, please call the

Prior Authorization of Benefits Center at (800) 338-6180

To submit your request via fax, complete this form in its entirety and fax to:

Prior Authorization of Benefits Center at (800) 601- 4829

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Medicare Part - D

transmucosal fentanyl citrate

Prior Authorization of Benefits (PAB) Form

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:

___________________________

Physician DEA:

___________________________

Patient Email Address: _________________________

Physician NPI #:

___________________________

Physician Email Address: ________________________

3. MEDICATION

4. STRENGTH

5. DIRECTIONS

6. QUANTITY PER 30 DAYS

Transmucosal Fentanyl Citrate

__________________

______________________

Specify: _________________

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.

What is the patient’s diagnosis? ______________________________________________________________________

What other medications has the patient tried for this diagnosis?

1. __________________________ Dates: ________________________ Outcome: ______________________________

2. __________________________ Dates: ________________________ Outcome: ______________________________

3. __________________________ Dates: ________________________ Outcome: ______________________________

□

□

Yes

No

Patient has cancer with breakthrough cancer pain

□

□

Yes

No

Patient is 16 years of age or older

□

□

Yes

No

Patient is receiving an opioid and is TOLERANT to opioid therapy defined as receiving (please indicate):

□

□

Yes

No

At least 60 mg morphine/day

□

□

Yes

No

At least 25 mcg/hr transdermal fentanyl/hour

□

□

Yes

No

At least 30 mg of oxycodone daily

□

□

Yes

No

At least 25 mg of oral oxymorphone daily

□

□

Yes

No

At least 8 mg of oral hydromorphone daily

□

□

Yes

No

An equianalgesic dose of another opioid for a week or longer

8. PHYSICIAN SIGNATURE

____________________________________________________________

__________________________________________

Prescriber or Authorized Signature

Date

Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what

medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions.

The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only

for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other

party unless required to do so by law or regulation.

If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of

these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or

destruction of these documents.

Med D transmucosal fentanyl citrate PAB Fax Form 01.11.16.doc