Oralair Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Oralair
(sweet vernal, orchard, perennial rye, Timothy,
and Kentucky blue grass mixed pollens allergen
extract)
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
Oralair (sweet vernal, orchard, perennial
___________
rye, Timothy, and Kentucky blue grass
_________________
Specify: _________________
mixed pollens allergen extract)
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
Does the patient have a diagnosis of grass pollen-induced allergic rhinitis?
□
□
Yes
No
Has the diagnosis been documented by one of the following (please indicate):
□
Positive skin test
□
Positive in vitro testing for pollen-specific IgE antibodies for at least one of the following five grass
pollens contained in Oralair (please indicate):
□
□
□
□
□
Sweet vernal
Orchard
Perennial rye
Timothy
Kentucky blue grass
□
□
Yes
No
Has the patient had a trial of and inadequate symptom control with one nasal steroid and one non-
sedating antihistamine?
□
□
Yes
No
Does the patient have a documented prescription for an auto-injectable epinephrine product?
□
□
Yes
No
Will treatment be initiated at least 16 weeks before the expected onset of grass pollen season and
continued throughout the season?
□
□
Yes
No
Is the patient between the ages of 10 and 65 years old?
□
□
Yes
No
Does the patient have severe, unstable or uncontrolled asthma?
□
□
Yes
No
Does the patient have a history of any severe systemic allergic reaction?
□
□
Yes
No
Is the patient also receiving therapy with other allergen immunotherapy products?
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Oralair NTL PAB Fax Form 07.11.14.doc
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