Selected Weight-Loss Drugs Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Selected Weight-loss drugs
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Prescribing Physician: ____________________________
Patient Name: __________________________________
Physician Address:
_____________________________
Patient ID #:
__________________________________
Physician Phone #:
_____________________________
Patient DOB: __________________________________
Physician Fax #:
_____________________________
Date of Rx:
__________________________________
Physician Specialty:
____________________________
Patient Phone #: _______________________________
Physician DEA:
____________________________
Patient Email Address: ___________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
□
Adipex-P (phentermine)
□
Belviq (lorcaserin)
□
Bontril PDM (phendimetrazine)
□
Bontril SR (phendimetrazine SR)
□
Contrave (naltrexone HCI, bupropion
HCI extended release)
□
Didrex (benzphetamine)
□
_____________
_____________________
_____________________
Melfiat (phendimetrazine)
□
Regimex (benzphetamine)
□
Qsymia (phentermine HCl, topiramate
extended release)
□
Saxenda (liraglutide)
□
Suprenza ODT (phentermine ODT)
□
diethylpropion
□
diethylpropion ER
7. DIAGNOSIS: ___________________________________________________________________________________
8. APPROVAL CRITERIA: CHECK ALL BOXES THAT APPLY
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
What is the patient’s current weight? Please Specify: _____________________
What is the patient’s BMI? Please Specify: _____________________
Initial requests:
□
□
Yes
No
Patient has attempted to lose weight through a formalized weight management program (hypocaloric
diet, exercise, and behavior modification) for at least 6 months prior to this request
□
□
Yes
No
Patient is currently on a reduced calorie diet and exercise program
□
□
Yes
No
Patient is receiving two medications for weight loss at the same time
Subsequent requests:
When did the patient begin the medication? Please Specify: _____________________
What was the patient’s weight prior to beginning the requested medication? Please Specify: _____________________
□
□
Yes
No
Patient has achieved/maintained an initial 5% weight loss or has continued to lose weight
□
□
Yes
No
Patient is currently maintained on a reduced calorie diet and exercise program
□
□
Yes
No
Patient is receiving two medications for weight loss at the same time
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Selected Weight-loss Drugs NTL PAB Fax Form 08.28.15.doc
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