Biologic Immunomodulators Prior Authorization Physician Fax Form
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1BIOLOGIC IMMUNOMODULATORS PRIOR
AUTHORIZATION
Physician Fax Form
Only the prescriber may complete this form. This form is for prospective, concurrent, and retrospective reviews.
The following documentation is REQUIRED for prior authorization. Incomplete forms will be returned for additional information. For formulary
information, please visit
PATIENT INFORMATION
Today’s Date:
Patient Name (First):
Last:
M:
DOB (mm/dd/yyyy):
__________________________
__________________________________________
___
______________________________
Patient Address:
City, State, Zip:
Patient Telephone:
INSURANCE INFORMATION
_______________________________________
___________________________
BCBS ID Number:
Group Number:
PHYSICIAN/CLINIC INFORMATION
Prescriber Name:
Physician NPI#:
Specialty:
Contact Name:
____________________________
__________________________________
______________
_________________________
Clinic Name:
Clinic Address:
City, State, Zip:
Phone #:
Secure Fax #:
______________________________________________
PLEASE ATTACH ANY ADDITIONAL INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST
Patient’s Diagnosis - ICD-9 code plus description:
_______________________________________________________
Medication Requested:
_______________________________________
Strength:
______________________________
Dosing Schedule:
___________________________________________
Quantity per Month:
____________________________
1.
Is the patient currently treated with the requested medication? ........................................................................
Yes
No
_______________________________________
If yes, when was treatment with the requested medication started?
2.
If the patient is currently prescribed the requested medication, has the treatment been beneficial
in achieving remission of the disease or decreasing symptom severity? ………………………………..............
Yes
No
3.
Has the patient been tested for latent pulmonary tuberculosis (TB)? ……………………………………………..
Yes
No
If the test was positive, has the patient been established on TB therapy? …………………………………
Yes
No
4.
For renewal of Amevive, has there been a minimum of 12 weeks since the end of the
previous course of Amevive? .............................................................................................................................
Yes
No
5.
Please list all other medications the patient is currently taking for treatment of this diagnosis.
6.
Please list the medications the patient has previously tried and failed for treatment of this diagnosis. Please specify if the
patient has tried brand-name products, generic products or over-the-counter.)
_____________________________
Date:
_____________________________
Date:
_____________________________
Date:
_____________________________
Date:
If the patient has been previously treated with another biologic (Enbrel, Humira, Kineret, Amevive,
7.
Cimzia, Orencia, Remicade, Rituxan, Simponi, Stelara, Xeljanz), will this drug be discontinued before
the requested medication is started? ………………………………………………………………………………
Yes
No
Please list all reasons for selecting the requested medication, strength, dosing schedule, and quantity over alternatives
8.
________________________________________
(e.g. contraindication to other medications; lower dose has been tried):
________________________________________________________________________________________________
Please fax or mail this form to:
CONFIDENTIALITY NOTICE: This communication is intended only for the use of the
Prime Therapeutics LLC, Clinical Review Department
individual entity to which it is addressed, and may contain information that is privileged
1305 Corporate Center Drive
or confidential. If the reader of this message is not the intended recipient, you are
Eagan, Minnesota 55121
hereby notified that any dissemination, distribution or copying of this communication is
strictly prohibited. If you have received this communication in error, please notify the
TOLL FREE
sender immediately by telephone at 866.274.5158, and return the original message to
Fax: 877.254.3787
Phone: 888.274.5158
Prime Therapeutics via U.S. Mail. Thank you for your cooperation.
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