Ampyra (Dalfampridine Er) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Ampyra (dalfampridine ER)

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

□

□

______________________

Specify: _________________

Ampyra (dalfampridine ER)

10mg

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.

Initial Treatment

□

□

Yes

No

Patient has a diagnosis of Multiple Sclerosis

□

□

Yes

No

Patient has a history of seizures

□

□

Yes

No

Patient has moderate or severe renal impairment

□

□

Yes

No

Patient has been objectively assessed for functional impairment related to ambulation

□

□

There is documentation in the chart regarding the patient’s functional impairment related to

Yes

No

ambulation or functional status

Continued Treatment

□

□

There has been clinically significant, sustained improvement in the patient’s ambulation or functional

Yes

No

status measured by objective office testing or by patient report

□

□

Yes

No

This improvement is documented in the chart either by exam in the office or by

patient history

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.

Ampyra NTL PAB Fax Form 03.31.11.doc

Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.