Ruconest (C1 Esterase Inhibitor [recombinant]) Prior Authorization Of Benefits (Pab) Form

ADVERTISEMENT

CONTAINS CONFIDENTIAL PATIENT INFORMATION
Ruconest (C1 esterase inhibitor [recombinant])
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
Ruconest (C1 esterase
________________
______________________
Specify: _________________
inhibitor [recombinant])
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 diagnosis of Hereditary Angioedema (HAE)
Yes
No
Diagnosis was confirmed by a C4 level below the lower limit of normal as defined by the laboratory
performing the test AND ONE of the following (please indicate):
□ C1 inhibitor (C1-INH) antigenic level below the lower limit of normal as defined by the laboratory
performing the test
□ C1-INH functional level below the lower limit of normal as defined by the laboratory performing the test
Yes
No
Patient has a history of moderate or severe attacks (for example, airway swelling, severe abdominal
pain, facial swelling, nausea and vomiting, painful facial distortion)
Yes
No
Ruconest (C1 esterase inhibitor [recombinant]) is being used for treatment of acute HAE attacks (not for
prophylaxis or in individuals with laryngeal attacks)
Yes
No
Patient is 13 years of age or older
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.
Ruconest NTL PAB Fax Form 12.19.14.doc

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go