Infertility Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Infertility
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.
Requests for Clomiphene Citrate:
□
□
Yes
No
Requested medication is being used for ovulation induction
□
□
Yes
No
Female individual with normogonadotropin anovulatory dysfunction such as polycystic ovary syndrome
(PCOS)
□
□
Yes
No
Young woman with unexplained infertility of short duration with normal levels of luteal progesterone and
a normal hysterosalpingogram.
□
□
Yes
No
Patient has Stage I or II endometriosis
Requests for Injectable Low Dose Follicle Stimulating Hormone (FSH) (Bravelle, Follistim AQ, Gonal-f, Gonal-f
RFF) or Menotropins (Repronex, Menopur)
□
□
Yes
No
Woman has hypogonadotropin anovulatory disorders or hypopituitarianism - these women are not
expected to respond to FSH alone, but will require additional therapy with an LH containing product,
either hCG or recombinant LH (Luveris) (This means that Luveris will be used at the same time as FSH)
□
□
Yes
No
Woman has normogonadotropion anovulatory disorders (that is, polycystic ovary syndrome) or those
with unexplained infertility who have not ovulated or conceived after a prior trial of three cycles of
clomiphene
□
□
Yes
No
Couples with severe male factor infertility
□
□
Yes
No
Female with bilateral tubal occlusion
□
□
Yes
No
Unexplained infertility that has not responded to ovarian induction therapy
□
□
Yes
No
The gonadotropins, in combination with hCG, for infertile men with hypogonadotropic hypogonadism
with onset prior to completion of pubertal development
□
□
Yes
No
The use of hCG alone, or in combination with FSH is to maintain spermatogenesis for infertile men with
post-pubertal acquired hypogonadotropic hypogonadism who have previously had normal sperm
production
□
□
Yes
No
The use of hCG alone, or in combination with FSH is to maintain spermatogenesis for infertile men with
partial gonadotropin deficiency
PAGE 1 OF 2 – CONTINUED ON PAGE 2
Infertility NTL PAB Fax Form 06.04.15.doc
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