Myobloc (Rimabotulinumtoxinb) Prior Authorization Of Benefits (Pab) Form Page 2
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1
2CONTAINS 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
PATIENT NAME: _________________________________ PATIENT ID #: ______________________________________
□
□
Yes
No
Individual has Hirschsprung disease and is being treated for functional obstruction caused by the inability of the
internal anal sphincter to relax
□
□
Yes
No
Individual has undergone prior surgical treatment
□
□
Yes
No
Individual has neurogenic overactive bladder (also referred to as detrusor overactivity or detrusor sphincter
dyssynergia
□
□
Yes
No
Diagnosis is adequately controlled with anticholinergic therapy
□
□
Yes
No
Individual has idiopathic overactive bladder
□
□
Yes
No
Individual is unresponsive to or intolerant of anticholinergic therapy
□
□
Yes
No
Individual is 18 years of age or older
□
□
Yes
No
Individual is diagnosed with chronic migraine headaches
□
□
Yes
No
Request is for initial treatment
□
□
Yes
No
Individual is an adult with fifteen (15) or more headache-days per month with headache
lasting four (4) hours per day or longer
□
□
Yes
No
The first episode was at least six (6) months ago
□
□
Yes
No
Symptoms have persisted despite trials of at least 1 agent in any 2 of the following classes of
medications used to prevent migraines or reduce migraine frequency: Antidepressants (for
example, amitriptyline, nortriptyline, doxepin), Antihypertensives (for example, propanolol,
timolol), Antiepileptics (for example, valproate, topiramate, gabapentin)
□
□
Yes
No
Request is for continued treatment
□
□
Individual has completed an initial 6 –month trial
Yes
No
□
□
Yes
No
Migraine headache frequency was reduced by at least 7 days per month (when compared to
pre-treatment average) by the end of the initial trial
□
□
Yes
No
Migraine headache duration was reduced by at least 100 total hours per month (when
compared to the pre-treatment average) by the end of the initial trial
□
□
Yes
No
Individual is being treated for primary hyperhidrosis
□
□
ndividual has failed a 6 month trial of any one or more types of nonsurgical
Yes
No
I
treatment (i.e., topical dermatologics such as aluminum chloride, tannic acid,
glutaraldehyde, anticholinergics; systemic anticholinergics, tranquilizers or non
steroid anti-inflammatory drugs)
□
□
resence of medical complications or skin maceration with secondary
Yes
No
Individual has a p
infection
□
□
has significant functional impairment, as documented in the medical
Yes
No
Individual
records
□
□
Yes
No
Individual is being treated for secondary hyperhidrosis
□
□
Individual’s
condition is related to surgical complications
Yes
No
□
□
resence of medical complications or skin maceration with secondary
Yes
No
Individual has a p
infection
□
□
has significant functional impairment, as documented in the medical
Yes
No
Individual
records
9. 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 submitting
provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.
Note: Payment is subject to member eligibility. Authorization does not guarantee payment.
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.
PAGE 2 OF 2
Myobloc NTL PAB Fax Form 01.18.16.doc
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