Striant (Testosterone) Prior Authorization Of Benefits (Pab) Form
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2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Striant (testosterone)
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
Striant (testosterone)
_____________________
______________________
Specify: _________________
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
Requested medication is being used for replacement therapy
□
□
Yes
No
Patient is male
□
□
Yes
No
Patient has a diagnosis of primary hypogonadism (congenital or acquired), such as but not limited to:
□
□
Cryptorchidism
Klinefelter Syndrome
□
□
Bilateral torsion
Chemotherapy
□
□
Orchitis
Toxic damage from alcohol or heavy metals
□
□
Vanishing testes syndrome
Other: _______________________
□
Orchiectomy
□
□
Yes
No
Patient has a diagnosis of hypogonadotropic hypogonadism (congenital or acquired), such as but
not limited to:
□
Idiopathic gonadotropin or luteinizing hormone-releasing hormone (LHRH) deficiency
□
Pituitary-hypothalamic injury
□
Other: _____________________
□
□
Yes
No
Patient is beginning treatment with topical testosterone; if yes, MUST provide initial and repeat (at
least 24 hours apart) morning total testosterone level: Initial ____________ Repeat: _________
□
□
Yes
No
Patient presents with symptoms associated with hypogonadism, such as but not limited to the
following:
□
Reduced sexual desire (libido) and activity
□
Decreased spontaneous erections
□
Breast discomfort/gynecomastia
□
Loss of body (axillary and pubic) hair, reduced shaving
□
Very small (especially less than 5 mL) or shrinking testes
□
Inability to father children or low/zero sperm count
□
Height loss, low trauma fracture, low bone mineral density
□
Hot flushes, sweats
□
Other less specific signs and symptoms including decreased energy, depressed mood/dysthymia,
irritability, sleep disturbance, poor concentration/memory, diminished physical or work
performance
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Striant NTL PAB Fax Form 10.15.15.doc
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