CONTAINS CONFIDENTIAL PATIENT INFORMATION
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 #:
Patient DOB: __________________________________
Physician Phone #:
Date of Rx:
Physician Fax #:
Patient Phone #: _______________________________
Patient Email Address: ___________________________
Physician NPI #:
Physician Email Address: ___________________________
6. QUANTITY PER 30 DAYS
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.
Is patient intolerant to the recommended drug regimen due to adverse side effects?
Has patient achieved desired results with the recommended drug regimen?
Is this patient able to use the recommended dosage forms?
If no, please specify why not __________________________________________________
Is patient’s dose commercially available as a once daily dose (QD)?
Is patient’s dose being titrated?
Requests will be approved up to the recommended maximum daily dosing limit that is supported by the FDA for the
approved indication, and as approved by the Wellpoint National Pharmacy and Therapeutics Committee. Requests for
quantities greater than the maximum daily dose will be reviewed for medical necessity.
Medical Justification:____________________________________________________________________________ ___
9. PHYSICIAN SIGNATURE
Prescriber or Authorized Signature
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.
Dose Opt NTL PAB Fax Form 03.27.13.doc