Form Frx0012 - Prior Authorization Request Form For Antifungalsdiflucan/lamisil/sporanox

FORM # FRX0012

Prior Authorization Request Form for Antifungals-

Diflucan/Lamisil/Sporanox

Member Information

Provider Information

Patient Name ____________________________ Provider Name _____________________________

Cardholder ID ___________________________ DEA Number ______________________________

Date of Birth ____________________________ Address ___________________________________

Address ________________________________ City, State and Zip ___________________________

City, State Zip ___________________________ Phone Number ______________________________

Phone Number ___________________________ FAX Number _______________________________

Pharmacy Information

Pharmacy Name___________________Address__________________Phone______________________

Criteria for Approval:

1. Antifugal requested: Check one (please include strength):

Diflucan_____

_____

_____

Lamisil

Sporanox

2. Does the patient have a diagnosis of one of the following?

Check all that apply:

Blastomycosis

Cryptococcal Meningitis

Aspergillis

Coccidiodomycosis

Disseminated Candida

Onychomyosis

Other ________________

Histoplasmosis

3. Has the diagnosis been confirmed by a KOH preparation or fungal culture? Yes

No

4. Has the patient been on the product requested for the previous 6 months?

Yes

No

5. Does the patient meet at least one of the following criteria? Check all that apply:

Patient is diabetic

Patient is immunocompromised due to AIDS, anti-rejection treatment, chemotherapy for cancer, etc

Patient has a systemic dermatosis with impaired skin integrity (i.e., pemphigus, ichthyosis)

Patient has peripheral vascular disease

Patient requires treatment of fingernails and/or toenails due to dermatophytes

Provider Signature _________________________________________ Date ________________________

Fax completed forms to (866) 284-4509.

For Office Use Only

Date/Time Received_____________________________________________________________________

Reference Number______________________________________________________________________

Approved / Denied (Circle One) by _____________________________ Date_______________________

Date/Time Returned to Provider___________________________________________________________

_____________________________________________________________________________________

If you have any questions regarding this form, contact the Prior Authorization Department Toll Free at

(866) 284-4492 or FAX Toll Free at (866) 284-4509.

FOX Rx Care Utilization Management

3375-I Capital Circle NE

Tallahassee, FL 32308

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