Quantity Supply Ondansetron Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Quantity Supply
ondansetron
Complete form in its entirety and fax to:
Prior Authorization of Benefits (PAB) 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 PER 30 DAYS
□
□
□
□
Zofran (ondansetron)
4mg
8mg
24mg
□
□
□
Zofran ODT (ondansetron)
4mg
8mg
_________________
Specify: _________________
□
□
Zofran oral solution (ondansetron)
4mg/ 5mL
□
□
□
Zuplenz oral film (ondansetron)
4mg
8mg
7. DIAGNOSIS: ______________________________________________________________________________
8.
CHECK ALL BOXES THAT APPLY NOTE:
APPROVAL CRITERIA:
Any areas not filled out are considered not
applicable to your patient & MAY AFFECT THE OUTCOME of this request
□
□
Yes
No
Patient will use for the prevention of chemotherapy or radiotherapy induced nausea and vomiting
If yes, which of the following will apply:
□
Zofran or Zofran ODT 4mg tablets or Zuplenz 4mg film 90 or 180 (if daily chemo or radiotherapy) per 30 days
□
Zofran or Zofran ODT 8mg tablets or Zuplenz 8mg film 45 or 90 (if daily chemo or radiotherapy) per 30 days
□
Zofran 24mg tablets 15 or 30 (if daily chemo or radiotherapy) per 30 days
□
Zofran 4mg/5mL oral solution 450mL or 900mL (if daily chemo or radiotherapy) per 30 days
□
Other: Please Specify: ___________________________________________________________________
□
□
Yes
No
Patient will use for the treatment of hyperemesis gravidarum
If yes, which of the following will apply:
□
Zofran or Zofran ODT 4mg tablets or Zuplenz 4 mg film 60 per 30 days AFTER metoclopramide, promethazine, or
prochlorperazine
□
Zofran or Zofran ODT 8mg tablets or Zuplenz 8mg film 30 per 30 days AFTER metoclopramide, promethazine, or
prochlorperazine
□
Zofran 24mg tablets 10 per 30 days AFTER metoclopramide, promethazine, or prochlorperazine
□
Zofran 4mg/5mL oral solution 300mL per 30 days AFTER metoclopramide, promethazine, or prochlorperazine
□
Other: Please Specify: ___________________________________________________________________
Note: Requests for an increase in quantity of ondansetron, and one of criteria above is not met, the request will be forwarded to the
plan for review.
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CONTINUED ON PAGE 2
ondansetron Quantity Supply NTL PAB Fax Form 10.20.10.doc
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
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