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Form Pca18562 - H.p. Acthar Gel (Repository Corticotropin Injection) Prior Authorization Page 2

H.P. Acthar Gel (repository corticotropin injection)

Prior Authorization Form

Medication Information

Medication:

H.P. Acthar Gel (J0800)

Dose: _______________________________________________________________________________

Directions: ______________________________________________________________________________________________________________

Quantity: _______________________________________________

Refills: ______________________

Duration of Treatment: ______________

Physician Signature: ______________________________________________________________________________________________________

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in this facsimile is intended to be for the sole use of the individual(s) or entity named above. If you are not the intended recipient, be aware that any disclosure, copying,

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please notify the sender immediately and destroy all electronic hard copies of the communications including attachments.

PCA18562

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