Azelastine Hydrochloride Quantity Supply Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Azelastine hydrochloride Quantity Supply

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:

_________________________

Physician NPI #:

_________________________

Patient Email Address: ________________________

Physician Email Address: ______________________

3. MEDICATION

4. STRENGTH

5. QUANTITY PER 30 DAYS

□

□

________________________

Azelastine hydrochloride (generic Optivar)

0.05% Solution (6mL bottle)

6. DIAGNOSIS: ___________________________________________________________________________________

CHECK ALL BOXES THAT APPLY

7. APPROVAL CRITERIA:

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

Specify dose and quantity desired for one month: ________________________________________________________

Who indicates more than 1 bottle per month is required (max allowable 20ml per 30 days with override)?

□

□

□

physician

pharmacist

member

□

□

Yes

No

Has the patient received a quantity override in the previous calendar year?

If yes, how many times? _______________________________________

Duration of therapy requested:___________________________________; If duration is 6 months to 1 year, physician

has submitted a letter with the member’s name, identification number, diagnosis, agent needed, dosage and brief

explanation as to why greater than the maximum allowed (20ml per 30 days) dosage or quantity is needed for an

extended amount of time.

□

□

Yes

No

Is the quantity requested greater than the maximum quantity (20ml per 30 days)

If yes, please medically justify: _______________________________________________________

_______________________________________________________________________________

8. 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.

Azelastine hydrochloride Quantity Supply NTL PAB Fax Form 05.03.11.doc

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