Non-Preferred Medications Request Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Non-Preferred Medications Request

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

__________________

_________________ _______________

: ________________

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

Patient has previously tried and failed 2 (two) preferred products: One of which is in the same

specific drug class; the other product has the same indication as the product requested

If yes, please indicate trials below

□

□

Yes

No

For combination products: patient has tried 2 (two) preferred products: One of which is in the same

specific class as at least one ingredient in the requested medication

If yes, please indicate trials below

□

□

Yes

No

For non-preferred antibiotics/ anti-virals/ anti-fungals: patient has tried and failed on preferred

antibiotic/ anti-viral/ anti-fungal product within the same route of administration

If yes, please indicate trial below

□

□

Yes

No

Patient has previously taken the requested non-preferred product for 6 months

If yes, please indicate trial below

□

□

Yes

No

Patient has a documented drug interaction

□

□

Yes

No

Patient has documented adverse drug experiences (side effects, adverse drug reaction)

Product 1: ________________________________________ Dates Tried: ____________________________________

Product 2: ________________________________________ Dates Tried: ____________________________________

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.

NF Medication Request NTL PAB Fax Form 03.01.10.doc

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