Gamastan S/d Prior Authorization Of Benefits (Pab) Form Page 2
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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
Patient Name: ___________________________________
Patient ID#: __________________________________
Post exposure prophylaxis to prevent or modify symptoms of measles (rubeola)
□
□
Yes
No
Patient is using for post exposure prophylaxis to prevent or modify symptoms of measles (rubeola)
□
□
Yes
No
GamaSTAN S/D will be administered within 6 days of exposure and not given concomitantly with a
vaccine containing the measles virus
□
□
Yes
No
Eligible exposed, non-immune individuals will receive a vaccine containing the measles virus greater
than or equal to 6 months after receiving intramuscular immune globulin
□
□
Yes
No
GamaSTAN S/D will be used in the following individuals considered at risk for severe disease and
complications (please indicate):
□
Infants less than 12 months of age
□
Previously unvaccinated and ineligible to receive a vaccine containing the measles virus (such as,
but not limited to, vaccine contraindication or an initial exposure greater than 72 hours)
□
No evidence of measles immunity
Post-exposure prophylaxis of varicella infection in susceptible individuals (such as, immunocompromised)
□
□
Yes
No
Patient is using as post-exposure prophylaxis of varicella infection in susceptible individuals (such
as, immunocompromised)
□
□
Yes
No
The varicella-zoster immune globulin (human) (VZIG) and immune globulin intravenous (IGIV) are
available
Post-exposure prophylaxis for rubella exposure to lessen the likelihood of infection and fetal damage
□
□
Yes
No
Patient is using as post-exposure prophylaxis administered within 72 hours of rubella exposure to
lessen the likelihood of infection and fetal damage
□
□
Yes
No
Patient is in the early stages of pregnancy, exposed to a confirmed case of rubella, and will not
consider terminating the pregnancy under any circumstance
Primary immunodeficiency disorder
□
□
Yes
No
Patient has been diagnosed with a primary immunodeficiency disorder (such as, but not limited to,
Bruton-type, sex-linked congenital agammaglobulinemia; agammaglobulinemia associated with
thymoma; and acquired agammaglobulinemia)
□
□
Yes
No
Patient is using as replacement therapy in the prophylactic treatment of serious infections, especially
infections caused by encapsulated bacteria
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
GamaSTAN S/D NTL PAB Fax Form 01.12.15.doc
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