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)
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Amnesteem NTL PAB Fax Form 08.20.15.doc