Prior Authorization Form Antidepressant - Express Scripts Page 2
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2 Yes
No
5. Does the patient have any potential drug interactions with fluoxetine (Prozac), fluvoxamine (Luvox), sertraline
(Zoloft), or paroxetine (Paxil)?
If yes, please list medications: _____________________________________________________________
_____________________________________________________________________________________
6. Please indicate which generic SSRI’s the patient has tried:
□
Citalopram (generic)
□
Paroxetine controlled-release (generic)
□
Escitalopram (generic)
□
Paroxetine (generic)
□
Fluoxetine delayed-release 90mg capsule (generic)
□
Sertraline (generic)
□
Fluoxetine (generic)
□
Other: _____________________________________
□
Fluvoxamine (generic)
Are there any other comments, diagnoses, symptoms, and/or any other information the
physician feels is important to this review?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Prescriber Signature: __________________________________________Date: ___________________
Office Contact Name: ___________________________ Phone Number: _________________________
Based upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you have any
questions about the process or required information, please contact our prior authorization team at the number listed on the top of this form.
Prior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. Only a
treating physician can determine what medications are appropriate for the patient. Please refer to the applicable plan for the detailed information
regarding benefits, conditions, limitations, and exclusions.
The document(s) accompanying this transmission may contain confidential health information. This information is intended only for the use of the
individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action
taken in reliance on the contents of these documents is strictly prohibited. If you received this information in error, please notify the sender
immediately and arrange for the return or destruction of the documents.
Antidepressant SSRI Step Therapy
7.31.2012
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