Drug Prior Authorization Form Secukinumab (Cosentyx) Page 3

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Navitus SpecialtyRx
Specialty Medication Prescription Form
Fax completed Specialty Medication Request Form AND Prior Authorization Form to:
Navitus Prior Authorization, Fax Number: 855-668-8551
The Specialty Prescription Form will be forwarded if Prior Authorization is approved.
PRESCRIBER INFORMATION
Prescriber First
Prescriber NPI:
& Last Name:
Office Contact/RN Name:
Prescriber Phone:
Prescriber Fax:
Prescriber
Mailing Address:
PATIENT INFORMATION
Please check one:
New Patient
Refill Request
Patient First
Patient
& Last Name:
Date of Birth:
Patient
Patient
Daytime Phone:
Home Phone:
Patient ID:
Navitus Group #:
Height:
Weight:
Primary Diagnosis:
Allergies:
SHIPPING INFORMATION
Ship Medication to (please check one):
Home
Other
Shipping Address (Street, City, State, Zip):
PRESCRIPTION INFORMATION
Drug Name
Strength
Instructions
Quantity # of
Date
Refill(s)
Needed
Prescriber Signature: _____________________________________________ Date: _____________
12/17/2015
Version 1.0

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