Myobloc (Rimabotulinumtoxinb) Prior Authorization Of Benefits (Pab) Form

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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.
Yes
No
Individual has previously taken any botulinum toxin product(s)
Yes
No
Individual has had a true clinical failure of this medication
Yes
No
Individual stopped the botulinum toxin product due to intolerance or allergic reaction
Yes
No
Individual has a diagnosis of Strabismus
Yes
No
Individual has a diagnosis of Achalasia
Yes
No
Individual has a diagnosis of Anal Fissures
Yes
No
Individual has significant drooling
Yes
No
If yes, can the patient tolerate scopolamine?
Yes
No
Individual has one of the following disorders associated with spasticity or Dystonia:
Blepharospasm
Orofacial Dyskinesia (that is, jaw closure
Spasmodic Torticollis
dystonia)
Organic Writer’s Cramp
Hereditary Spastic
Symptomatic Torsion Dystonia
Paraparesis
Spasmodic Dysphonia / Laryngeal
Multiple Sclerosis
Cervical Dystonia
Dystonia
Schilder’s Disease
Cerebral Palsy
Facial Nerve (VII) Dystonia
Spasticity from Stroke,
Neuromyelitis Optica
Hemifacial spasm
Spinal Cord Injury or traumatic
Spastic Hemiplegia
Forms of Upper Motor Neuron Spasticity
brain injury
Idiopathic Torsion Dystonia
This is the individual’s initial treatment of Cervical Dystonia (spasmodic torticollis)
Yes
No
Yes
No
Individual has moderate to severe Cervical Dystonia
Yes
No
Individual has a history of recurrent clonic and/or tonic involuntary contractions of one or more of the following
muscles:
stemocleidomastoid
splenius
trapezius
posterior cervical muscles
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:
________________________________________
Yes
No
This request is for subsequent injections of botulinum toxin for the treatment of cervical dystonia (spasmodic
toricollis)
Yes
No
There is a response to the initial treatment documented in the medical records
PAGE 1 OF 2, CONTINUED ON PAGE 2
Myobloc NTL PAB Fax Form 01.18.16.doc

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