Striant (Testosterone) Prior Authorization Of Benefits (Pab) Form Page 2
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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
PATIENT NAME: ___________________________________ PATIENT ID #: ____________________________________
□
□
Yes
No
Patient has tried and failed either Androgel, Axiron, OR Testim in the past 180 days
□
□
Yes
No
Patient has untreated obstructive sleep apnea (OSA)
□
□
Yes
No
Patient has polycythemia as defined by hematocrit greater than 50%
□
□
Yes
No
Patient has severe congestive heart failure (CHF)
□
□
Yes
No
Patient has known, suspected, or history of prostate cancer
□
□
Yes
No
Patient has undergone radical prostatectomy
□
□
Yes
No
Prostate cancer was organ-confined
□
□
Yes
No
Patient has been disease free for two (2) years and has an undetectable
prostate-specific antigen (PSA) level (such as <0.1 ng/dl)
□
□
Yes
No
Patient is 18 years of age or older
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.
PAGE 2 OF 2
Striant NTL PAB Fax Form 10.15.15.doc
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