Tysabri (Natalizumab) Prior Authorization Of Benefits (Pab) Form
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2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Tysabri (natalizumab)
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
Tysabri (natalizumab)
______________________
______________________
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
Patient has a relapsing form of multiple sclerosis (MS)
□
□
Yes
No
Tysabri (natalizumab) is being used as monotherapy
□
□
Yes
No
Patient has had an inadequate response to, or is unable to tolerate, alternative
treatments for MS
□
□
Yes
No
Patient is enrolled in and has met all conditions of the MS Touch Prescribing
Program
□
□
Patient is an adult with moderate to severe Crohn’s disease (CD)
Yes
No
□
□
Yes
No
Patient has evidence of inflammation
□
□
Yes
No
Tysabri (natalizumab) is being used for induction and maintenance of clinical
response and remission
□
□
Yes
No
Patient has had an inadequate response to, or is unable to tolerate
conventional CD therapies and inhibitors of TNF-a
□
□
Yes
No
Patient is enrolled in and has met all conditions of the CD Touch Prescribing
Program
□
□
Yes
No
Patient has a type of MS other than relapsing forms
□
□
Yes
No
Patient is currently responsive to and tolerating another treatment for the prescribed indication
□
□
Yes
No
Patient has current or prior history of progressive multifocal leukoencephalopathy (PML)
□
□
Yes
No
Patient has a medical condition which significantly compromises the immune system including HIV
infection or AIDS, leukemia, lymphoma or organ transplantation
□
□
Yes
No
Patient is receiving chronic antineoplastics or immunosuppressants (for example, azathioprine)
□
□
Yes
No
Patient is receiving any other immune system modifying drug such as interferon beta-1 (for example,
Avonex)
□
□
Patient has positive test results for anti – John Cunningham virus (JCV) antibodies
Yes
No
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Tysabri PAB Fax Form 04.29.15.doc
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