Aciphex (Rabeprazole) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
AcipHex (rabeprazole)
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
___________________
AcipHex (rabeprazole)
__________________________
_______________________
7. DIAGNOSIS: ______________________________________________________________________________________
8. CLINICAL INFORMATION - NOTE: Any areas not filled out are considered not applicable to your patient & MAY
AFFECT THE OUTCOME of this request.
Please indicate patient’s age: _______
□
□
Yes
No
Patient is currently taking Plavix (clopidogrel)
□
□
Yes
No
IF TAKING PLAVIX (clopidogrel), patient has had a trial of, and inadequate response or
intolerance to, the Preferred proton pump inhibitors (PPIs) (lansoprazole and
pantoprazole)
□
□
Yes
No
IF NOT TAKING PLAVIX (clopidogrel), patient has had a trial of, and inadequate
response or intolerance to, four of the Preferred PPIs (Brand Nexium 40mg,
lansoprazole, omeprazole, pantoprazole, omeprazole/sodium bicarbonate capsules,
Nexium Suspension)
□
□
Yes
No
The preferred PPIs are FDA-approved for the prescribed indication
□
□
Yes
No
The preferred PPIs are unacceptable due to concomitant clinical situations, such as but not limited to a
known disease state or medications contraindications which is not also associated with the requested
product (for example inability to swallow tablets/capsules or age)
Quantity Limits - Proton pump inhibitors are limited to 1 dose per day [1 cap/tab/pkt per day]
Requests for increased quantity please answer the following:
Increased Dosing up to 2 doses/day may be approved if the following apply:
□
□
Yes
No
Patient tried once a day dosing [for 30 days], failed, and needs twice a day dosing
□
□
Yes
No
Patient has been diagnosed with eosinophilic esophagitis
Increased Dosing of 2 per day for 14 days may be approved if the following diagnosis applies:
□
□
Yes
No
H. pylori, for eradication
Increased Dosing beyond 2 doses/day may be approved if the following diagnosis apply:
□
□
Yes
No
Hypersecretory syndrome (Zollinger-Ellison syndrome, multiple endocrine adenomas, or systemic
Mastocytosis)
□
□
Barrett’s Esophagus
Yes
No
□
□
Yes
No
Laryngeal, esophageal or gastric cancer
□
□
Yes
No
Scleroderma or limited scleroderma (CREST syndrome)
PAGE 1 OF 2 – CONTINUED ON PAGE 2
AcipHex NTL PAB Fax Form 09.09.15.doc
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