Fillable Advair / Dulera / Symbicort - Prior Authorization Request Form printable pdf download

URGENT – 24 HOUR REQUEST

ADVAIR / DULERA / SYMBICORT

PRIOR AUTHORIZATION REQUEST FORM

Complete ENTIRE form and Fax to: 866-940-7328

SECTION A - PATIENT INFORMATION

Today‘s Date:

First Name:

Last Name:

Member ID #:

Address:

City:

State:

Zip:

Phone:

DOB:

Allergies:

Primary Insurance:

Policy #:

Group #:

□

NEW

CONTINUATION of THERAPY

Is the requested medication

or a

? If so, start date:_____________

□

Is this patient currently hospitalized?

Yes

SECTION B - PHYSICIAN INFORMATION

First Name:

Last Name:

M.D./D.O.

Address:

City:

State:

Zip:

Phone:

Fax:

NPI #:

Specialty:

Office Contact Name / Fax Attention to:

Medication:

Strength:

Directions for use:

ICD 10 Code:

Diagnosis (Please be specific & provide as much information as possible):

For Asthma:

Did the patient exhibit an inadequate response to treatment with at least a 30 day trial of an inhaled corticosteroid?

(e.g. Flovent, Asmanex, Pulmicort, Azmacort, or Qvar)

Yes____ No____ If yes, provide name of medication

and dates of therapy: _________________________________________________________________________

Did the patient experience an intolerance/adverse reaction to previous therapy or has a documented

contraindication to treatment with an inhaled corticosteroid? (e.g. Flovent, Asmanex, Pulmicort, Azmacort, or

Qvar) Yes____ No____ If yes, provide details:__________________________________________________________

Is this patient’s asthma diagnosis confirmed as severe persistent asthma? Yes____ No____ If yes, provide date

of diagnosis:________________________________________________________________________________

For COPD (Emphysema, Chronic Bronchitis):

Has the patient exhibited an inadequate response to treatment with at least a 60 day trial of EITHER a long-

acting beta2-agonist (e.g. Foradil, Serevent) OR an orally inhaled anticholinergic agent (e.g. Spiriva, Atrovent,

Combivent)?

Yes____ No____

If yes, provide name of medication and dates of therapy:

__________________________________________________________________________________________

Has the patient exhibited an intolerance/adverse reaction to previous therapy with at least a two-month trial of a

long-acting beta2-agonist (e.g. Foradil, Serevent) OR an orally inhaled anticholinergic agent (e.g. Spiriva,

Atrovent, Combivent)?

Yes____ No____

If yes, provide details:

__________________________________________________________________________________________

: ________________________

_______________

Physician Signature

Date:

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Phone: 800-310-6826

Fax: 866-940-7328

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