Xenical (Orlistat) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Xenical (orlistat)

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

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

□

Xenical (orlistat)

______________________

Specify: _________________

120mg

7. DIAGNOSIS: ___________________________________________________________________________________

8. APPROVAL CRITERIA: CHECK ALL BOXES THAT APPLY

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

□

□

Yes

No

Is the request for initial fill?

□

□

Yes

No

Is the request for subsequent fill (refill)?

□

□

Yes

No

If applicable, when did the patient begin the medication? Please Specify: _____________________

□

□

Yes

No

What is the patient’s current weight? Please Specify: _____________________

□

□

Yes

No

If applicable, what was the patient’s weight prior to beginning the requested medication?

Please Specify: _____________________

□

□

Yes

No

If applicable, has the patient maintained their initial weight loss or continued to lose weight with

Xenical?

□

□

Yes

No

What is the patient’s BMI? Please Specify: _____________________

□

□

Yes

No

Does the patient have any of the following risk factors (please specify)?

□

□

□

Diabetes

Controlled hypertension

Dyslipidemia

□

□

Yes

No

Is the patient currently on a reduced calorie diet?

□

□

Yes

No

Has the patient been taking Xenical for less than 4 years?

□

□

Yes

No

Is the patient taking a multi-vitamin containing fat-soluble vitamins?

□

□

Yes

No

Is the patient receiving two medications for weight loss at the same time?

□

□

Yes

No

Does the patient have any of the following (please specify)?

□

□

□

Hypersensitivity to orlistat

Cholestasis

Chronic malabsorption syndrome

***State laws or regulations regarding weight loss drugs will supersede these criteria***

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.

Xenical NTL PAB Fax Form 03.10.15.doc