Form Frx0015 - Prior Authorization Request - Amphetamine/methylphenidate Products

FORM # FRX0015

Prior Authorization Request Form for

Amphetamine/Methylphenidate Products

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______________________

Name of drug and strength requesting:___________________________________

Criteria for Approval:

1. If requesting an Amphetamine product, is the patient 3 years of age or older? Yes

No

OR

If requesting a Methylphenidate product, is the patient 6 years of age or older? Yes

No

2. Has the patient been on an Amphetamine/D-Amphetamine or a Methylphenidate

product for the previous 6months?

Yes

No

3. Diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD)?

Yes

No

4. Diagnosis of Narcolepsy?

Yes

No

5. Have any of the following requirements been met? Check all that apply:

Yes

No

ADHD symptoms displayed in more than one setting (i.e., school, work, home, etc)

ADHD symptoms displayed for at least 6 months

ADHD symptoms significantly impair social, academic, or occupational functioning

No other psychiatric disorders to explain hyperactivity

Narcolepsy confirmed in sleep studies

No other extraneous causes for excessive daytime sleepliness (i.e., depression, insufficient sleep

ndro

syndrome, nighttime insomnia, or upper airway resistance syndrome)

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 Utiliaztion Management

3375-1 Capital Circle NE

Tallahassee, FL 32308

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