Form Frx024 - Prior Authorization Request - Hepatitis B Vaccine

FORM # FRX024

Prior Authorization Request Form for Hepatitis B Vaccine

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 _______________________________

Criteria for Approval:

1. Which agent is requested?

Engerix-B (Hepatitis B Recombinant)

Recombivax-B (Hepatitis B Recombinant)

Bayhep B (Hepatitis B Immune Globin)

Nabi-HB (Hepatitis B Immune Globin) Nabi-

HB Nova Plus (Hepatitis B Immune Globin)

2. Is the patient 18 years of age or older?

Yes

No

3. Is the vaccine to be used to treat individuals who are at high to moderate risk of

developing Hepatitis B?

Yes

No

4. Is the patient:

an individual with End stage renal disease (ESRD)

a hemophiliac who received Factor VIII or IX concentrations

a client of an institution for individuals for the mentally handicapped

who lives in the same household as a hepatitis B virus (HBV) carrier

a homosexual male

an illicit injectable drug abuser

a worker in the health care profession who has frequent contact with blood or blood-derived

body fluids during routine work

a staff member in an institution for the mentally handicapped

5. Is the vaccine being provided a part of a routine immunization? Yes

No

Provider Signature _________________________________________ Date ________________________

Fax completed forms to (866) 284-4509

.

For Office Use Only

Date/TimeReceived_____________________________________________________________________

ReferenceNumber_______________________________________________________________________

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 CareUtilization Management

3375-I Capital Circle NE

Tallahassee, FL 32308

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