Adoxa (Doxycycline) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Adoxa (doxycycline)

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

Patient Name: _______________________________

Prescribing Physician: __________________________

Patient ID #:

_______________________________

Physician Address:

__________________________

Patient DOB: _______________________________

Physician Phone #:

__________________________

Date of Rx:

_______________________________

Physician Fax #:

__________________________

Patient Phone #. _____________________________

Physician Specialty:

__________________________

Patient Email Address: ________________________

Physician DEA:

__________________________

Physician NPI #.

__________________________

Physician Email Address: _______________________

3. MEDICATION

4. STRENGTH

5. DIRECTIONS

6. QUANTITY PER 30 DAYS

□

Adoxa tablets (doxycycline)

□

Adoxa capsules (doxycycline)

__________________

___________________

Specify: _________________

□

Adoxa kit (doxycycline)

□

Adoxa pak (doxycycline)

7. DIAGNOSIS: ___________________________________________________________________________________

CHECK ALL BOXES THAT APPLY

8. APPROVAL CRITERIA:

NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.

□

□

Yes

No

Patient is 8 years of age or older

□

□

Yes

No

Patient has had a trial of generic immediate-release minocycline

□

□

Yes

No

Patient has had a trial of generic immediate-release doxycycline

□

□

Yes

No

Patient has a contraindication to either generic immediate-release minocycline OR generic immediate-

release doxycycline

□

□

Yes

No

Patient has had a trial of one of the following:

□

□

□

tetracycline

erythromycin

sulfamethoxazole-trimethoprim

NOTE: Patients requesting doxycycline products for the treatment of Anthrax or Rocky Mountain Spotted Fever should be

encouraged to use the generic doxycycline products available.

9. PHYSICIAN SIGNATURE

____________________________________________________________

__________________________________________

Prescriber or Authorized Signature

Date

Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what

medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting

provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.

Note: Payment is subject to member eligibility. Authorization does not guarantee payment.

The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only

for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other

party unless required to do so by law or regulation.

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 have received this information in error, please notify the sender immediately and arrange for the return or

destruction of these documents.

Adoxa NTL PAB Fax Form 07.24.12.doc