Multi-Source Brand Medications Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Multi-Source Brand Medications

Complete form in its entirety and fax to:

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

1. PATIENT INFORMATION

2. PHYSICIAN INFORMATION

Prescribing Physician: ____________________________

Patient Name: _________________________________

Physician Address:

_____________________________

Patient ID #:

_________________________________

Physician Phone #:

_____________________________

Patient DOB: _________________________________

Physician Fax #:

_____________________________

Date of Rx:

_________________________________

Physician Specialty:

____________________________

Patient Phone #: ______________________________

Physician DEA:

____________________________

Patient Email Address: __________________________

Physician NPI #:

_____________________________

Physician Email Address: ___________________________

3. MEDICATION

4. STRENGTH

5. DIRECTIONS

6. QUANTITY PER 30 DAYS

______________________

______________________

____________________

Specify: _________________

7. DIAGNOSIS: ___________________________________________________________________________________

CHECK ALL BOXES THAT APPLY

8. APPROVAL CRITERIA:

NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.

□

□

Yes

No The patient has failed an adequate trial of a chemically equivalent generic agent, by 2

different manufacturers (when available by at least 2 manufacturers)

□

□

Yes

No Generics have inadequate response

□

□

Yes

No Generics caused adverse outcome

□

□

Yes

No The patient has a genuine allergic reaction to an inactive ingredient in generic agent(s). Allergic

reaction(s) must be clearly documented in the patient's medical record.

GI upset or irritation is not generally considered an allergy or failed treatment. Patients should be referred to their

Note:

physician or pharmacist for advice on dose adjustment, and/or other options to reduce GI upset/irritation. Common

documented side effects attributed to the drug (i.e. headache, nausea, blurred vision, fatigue, muscle aches) are not

considered an allergy and would be expected to occur at the same level in both the generic and brand agent.

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.

MSB Medications NTL PAB Fax Form 03.24.11.doc

Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.