CONTAINS CONFIDENTIAL PATIENT INFORMATION
Myobloc (rimabotulinumtoxinB)
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 PER 30 DAYS
Myobloc (rimabotulinumtoxinB)
_______________________
______________________
Specify: _________________
7. DIAGNOSIS: _____________________________________________________________________________________________
8. 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.
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Yes
No
Individual has previously taken any botulinum toxin product(s)
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Yes
No
Individual has had a true clinical failure of this medication
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Yes
No
Individual stopped the botulinum toxin product due to intolerance or allergic reaction
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Yes
No
Individual has a diagnosis of Strabismus
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Yes
No
Individual has a diagnosis of Achalasia
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Yes
No
Individual has a diagnosis of Anal Fissures
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Yes
No
Individual has significant drooling
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Yes
No
If yes, can the patient tolerate scopolamine?
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Yes
No
Individual has one of the following disorders associated with spasticity or Dystonia:
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Blepharospasm
Orofacial Dyskinesia (that is, jaw closure
Spasmodic Torticollis
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dystonia)
Organic Writer’s Cramp
Hereditary Spastic
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Symptomatic Torsion Dystonia
Paraparesis
Spasmodic Dysphonia / Laryngeal
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Multiple Sclerosis
Cervical Dystonia
Dystonia
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Schilder’s Disease
Cerebral Palsy
Facial Nerve (VII) Dystonia
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Spasticity from Stroke,
Neuromyelitis Optica
Hemifacial spasm
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Spinal Cord Injury or traumatic
Spastic Hemiplegia
Forms of Upper Motor Neuron Spasticity
brain injury
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Idiopathic Torsion Dystonia
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This is the individual’s initial treatment of Cervical Dystonia (spasmodic torticollis)
Yes
No
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Yes
No
Individual has moderate to severe Cervical Dystonia
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Yes
No
Individual has a history of recurrent clonic and/or tonic involuntary contractions of one or more of the following
muscles:
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stemocleidomastoid
splenius
trapezius
posterior cervical muscles
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Yes
No
Individual has sustained head tilt and/or abnormal posturing with limited range of motion in the neck
Please indicate the duration of the patient’s condition:
________________________________________
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Yes
No
This request is for subsequent injections of botulinum toxin for the treatment of cervical dystonia (spasmodic
toricollis)
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Yes
No
There is a response to the initial treatment documented in the medical records
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Myobloc NTL PAB Fax Form 01.18.16.doc