Actos (Pioglitazone Hcl) Prior Authorization Of Benefits (Pab) Form
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1CONTAINS CONFIDENTIAL PATIENT INFORMATION
®
Actos
(pioglitazone hcl)
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
□
15mg
Specify: _________________
□
□
__________________________
Actos (pioglitazone hcl)
30mg
(QL:
1 per day dosing)
□
45mg
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’s glucose is controlled on a once daily dose
□
□
Yes
No
Patient is intolerant to a once daily dose
□
□
Yes
No
Quantity requested is greater than one per day
If yes, please indicate quantity & reason:_______________________________________________
________________________________________________
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.
Actos Quantity Supply 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.
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