Gamastan S/d Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
GamaSTAN S/D
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:
____________________________
Patient Email Address: ___________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
□
□
GamaSTAN S/D
______________________
Specify: _________________
15%
18%
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.
Pre-exposure prophylaxis for hepatitis A virus (HAV)
□
□
Yes
No
Patient is using as pre-exposure prophylaxis for hepatitis A virus (HAV)
□
□
Yes
No
Patient will receive the intramuscular injection prior to anticipated exposure
□
□
Yes
No
Patient has clinical manifestations of hepatitis A
□
□
Yes
No
Patient is previously unvaccinated and one of the following (please indicate):
□
Patient is unable to receive HAV vaccine (such as, under the age of 12 months or contraindication
to or unavailability of the vaccine)
□
Patient is considered high-risk (such as, travel to an endemic area, older adults,
immunocompromised, or diagnosis of chronic liver disease) and will receive a simultaneous dose
of HAV vaccine unless contraindicated
Post-exposure prophylaxis for hepatitis A virus (HAV)
□
□
Yes
No
Patient is using as post-exposure prophylaxis for hepatitis A virus (HAV)
□
□
Yes
No
Patient will receive the intramuscular injection within 2 weeks of exposure
□
□
Yes
No
Patient has clinical manifestations of hepatitis A
□
□
Yes
No
Patient is previously unvaccinated and one of the following (please indicate):
□
Patient is under the age of 12 months or over 40 years of age
□
Patient is between the ages of 12 months and 40 years and unable to receive the hepatitis A virus
vaccine (such as, contraindication to or unavailability of the vaccine)
□
Patient is considered high-risk (such as, immunocompromised, diagnosis of chronic liver disease,
or vaccine contraindication)
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GamaSTAN S/D NTL PAB Fax Form 01.12.15.doc
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