Zohydro Er (Hydrocodone Bitartrate Extended-Release) Prior Authorization Of Benefits (Pab) Form
ADVERTISEMENT
1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Zohydro ER
(hydrocodone bitartrate extended-release)
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
□
□
□
10mg
15mg
20mg
Zohydro ER (hydrocodone
__________________
Specify: _________________
□
□
□
bitartrate extended-release)
30mg
40mg
50mg
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
Is the patient 18 years of age or older?
□
□
Yes
No
Does the patient have a diagnosis of pain severe enough to require daily, around-the-clock, long
term opioid treatment?
□
□
Yes
No
Has the patient had an inadequate response to alternative treatment options, such as but not limited
to non-opioid analgesics and immediate-release opioids?
□
□
Yes
No
Are alternative treatment options otherwise inadequate to provide sufficient management of pain?
□
□
Yes
No
Has the patient completed titration and is already maintained on a stable dose of Zohydro ER?
□
□
Yes
No
Has the patient had a trial and inadequate response or intolerance to any two preferred long-acting
agents?
If yes, please indicate:
□
□
□
□
Fentanyl Patch
Levorphanol
Methadone
Methadose
□
□
□
□
Morphine Sulfate ER
Tramadol ER
Oxymorphone ER
Hydromorphone ER
□
□
Yes
No
Are the preferred long-acting opioids not acceptable due to concomitant clinical situations, such as
but not limited to (please indicate):
□
Known hypersensitivity to any ingredient which is not also in Zohydro ER
□
Known disease state or medication contraindication which is not also associated with Zohydro ER
□
Other: _______________________________________________________________________
□
□
Yes
No
Does the patient have a need for an abuse deterrent formulation based upon a history of substance
abuse disorder OR patient's family member or household resident has active substance abuse
disorder or a history of substance abuse disorder?
□
□
Yes
No
Is the patient requesting or using Zohydro ER (hydrocodone bitartrate extended-release) as an as-
needed analgesic?
□
□
Yes
No
Does the patient have any of the following conditions? If yes, please indicate:
□
□
Significant respiratory depression
Acute or severe bronchial asthma or hypercarbia
□
Known or suspected paralytic ileus
PAGE 1 OF 2, CONTINUED ON PAGE 2
Zohydro ER NTL PAB Fax Form 11.25.15.doc
ADVERTISEMENT
0 votes
Related Articles
Related forms
Hysingla Er (hydrocodone Bitartrate Extended Release) Prior Authorization Of Benefits (pab) Form
Business
Xigduo Xr (dapagliflozin/metformin Extended-release) Prior Authorization Of Benefits (pab) Form
Business
Xigduo Xr (dapagliflozin/metformin Extended-release) Prior Authorization Of Benefits (pab) Form
Business
Related Categories
Parent category: Business