Prior Authorization Form Antidepressant - Express Scripts

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Prior Authorization Form
Antidepressant SSRI Step Therapy
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-800-357-9577
applicable to all patients; certain plans and situations may require
additional information beyond what is specifically requested.
If this an URGENT request, please call 1-800-417-8164
Additional forms available:
Patient Information
Prescriber Information
Patient First Name: ______________________________
Prescriber Name: _________________________________
Prescriber DEA/NPI (required): ______________________
Patient Last Name: _______________________________
Prescriber Phone #: _______________________________
Patient ID#: _____________________________________
Prescriber Fax #: _________________________________
Patient DOB: ____________________________________
Prescriber Address: _______________________________
Patient Phone #: _________________________________
State: ________________ Zip Code: __________________
Primary Diagnosis: _________________________________ ICD Code: ________________________________________
Please indicate which drug and strength is being requested:
Celexa 10mg
Paxil 10mg
Pexeva 30mg
Sarafem 20mg Tablet
Celexa 20mg
Sarafem 20mg Capsule
Paxil 20mg
Pexeva 40mg
Celexa 40mg
Viibryd 10mg
Paxil 30mg
Prozac 10mg
Celexa 10mg/5ml Solution
Viibryd 20mg
Paxil 40mg
Prozac 20mg
Lexapro 5mg
Viibryd 40mg
Paxil 10mg/5mg Solution
Prozac 40mg
Lexapro 10mg
Paxil CR 12.5mg
Prozac 20mg/5ml Solution
Viibryd Starter Kit
Lexapro 20mg
Zoloft 25mg
Paxil CR 25mg
Prozac Weekly 90mg
Lexapro 5mg/5ml Solution
Paxil CR 37.5mg
Sarafem 10mg Tablet
Zoloft 50mg
Luvox CR 100mg
Zoloft 100mg
Pexeva 10mg
Sarafem 10mg Capsule
Luvox CR 150mg
Zoloft 20mg/ml Solution
Pexeva 20mg
Sarafem 15mg Tablet
Other: __________________
________________________
Directions for use (i.e. QD, BID, PRN & Qty):
___________________________________________________________________________________
_
Please complete the clinical assessment:
 Yes
 No
1. Is the patient currently taking the requested medication?
If yes, how long has the patient been taking the medication? _____________________________________
 Yes
 No
2. Is the patient taking samples or paying 100% out of pocket for the medication being requested?
If no, please indicate:
Requested medication covered under previous insurance plan
Started medication in hospital
Other: ___________________________________________________________________
 Yes
 No
3. Was the patient on this medication on a previous occasion?
 Yes
 No
4. Is the patient suicidal?

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