Lescol (Fluvastatin) & Lescol Xl (Fluvastatin Xl) Prior Authorization Of Benefits (Pab) Form (Page 2 of 2) in pdf

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Lescol (fluvastatin) & Lescol XL (fluvastatin XL)

Prior Authorization of Benefits (PAB) Form

Complete form in its entirety and fax to:

Prior Authorization of Benefits Center at (800) 601- 4829

Patient Name: ___________________________________

Patient ID#: ______________________________________

□

Yes

Patient is currently on an agent that interacts with both preferred generic and the preferred branded statin

Please specify product: _________________________________________________

*Note: If the patient had elevated CPK or LFTs, they should return to normal limits prior to initiation of therapy with

another statin. If the patient has a diagnosis of rhabdomyolysis, clinical symptoms (such as myalgia, generalized

weakness, and hemoglobinuria) and CK levels should return to the patient’s baseline or deemed appropriate by the

provider prior to initiation of therapy with another statin/statin combination.

10. 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.

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Lescol, Lescol XL NTL PAB Fax Form 12.12.15.doc