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:
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Celexa 10mg
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Paxil 10mg
Pexeva 30mg
Sarafem 20mg Tablet
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Celexa 20mg
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Sarafem 20mg Capsule
Paxil 20mg
Pexeva 40mg
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Celexa 40mg
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Viibryd 10mg
Paxil 30mg
Prozac 10mg
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Celexa 10mg/5ml Solution
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Viibryd 20mg
Paxil 40mg
Prozac 20mg
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Lexapro 5mg
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Viibryd 40mg
Paxil 10mg/5mg Solution
Prozac 40mg
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Lexapro 10mg
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Paxil CR 12.5mg
Prozac 20mg/5ml Solution
Viibryd Starter Kit
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Lexapro 20mg
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Zoloft 25mg
Paxil CR 25mg
Prozac Weekly 90mg
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Lexapro 5mg/5ml Solution
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Paxil CR 37.5mg
Sarafem 10mg Tablet
Zoloft 50mg
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Luvox CR 100mg
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Zoloft 100mg
Pexeva 10mg
Sarafem 10mg Capsule
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Luvox CR 150mg
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Zoloft 20mg/ml Solution
Pexeva 20mg
Sarafem 15mg Tablet
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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:
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Requested medication covered under previous insurance plan
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Started medication in hospital
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Other: ___________________________________________________________________
Yes
No
3. Was the patient on this medication on a previous occasion?
Yes
No
4. Is the patient suicidal?