Amnesteem (Isotretinoin) Prior Authorization Of Benefits (Pab) Form

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CONTAINS CONFIDENTIAL PATIENT INFORMATION
Amnesteem (isotretinoin)
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: ___________________________
Manufacturer Risk Management Programs (S.M.A.R.T., S.P.I.R.I.T., I.M.P.A.R.T., A.L.E.R.T.)
All prescriptions must have a Qualification Sticker filled out and
Initiation of therapy for female patients: require 2 negative pregnancy tests
Subsequent months: 1 negative pregnancy test monthly
Prescribe no more than a 30-day supply
Refills via phone, fax, or in an electronic format are NOT valid
Patients must review and sign the information/Consent Form
Prescriptions for female patients must be filled within 7 days
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
Amnesteem (isotretinoin)
____________________
______________________
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 a diagnosis of severe, recalcitrant, nodular acne If Yes:
Yes
No
Patient has responded to a trial of conventional therapy with at least one topical and
one systemic antibiotic acne treatment
Yes
No
Patient has a diagnosis of severe, refractory rosacea
Yes
No
Patient has a diagnosis of mild-to-moderate acne If Yes:
Yes
No
Patient has responded to a trial of conventional therapy with at least one topical and
one systemic antibiotic acne treatment
Yes
No
Patient has a diagnosis of psoriasis If Yes:
Yes
No
Patient has had an inadequate response to, is intolerant of, or has a contraindication to
conventional therapy
Yes
No
The requested medication is being used to control pustulation and systemic symptoms
associated with pustular psoriasis
Yes
No
The requested medication is being used in combination with psoralen and UVA light
(PUVA therapy) for severe psoriasis
Yes
No
The requested medication is being used in combination with a biologic agent for
chronic plaque psoriasis
Yes
No
Patient has a diagnosis of mycosis fungoides (MF)/Sezary syndrome (SS)
PAGE 1 OF 2
CONTINUED ON PAGE 2
Amnesteem NTL PAB Fax Form 08.20.15.doc

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