Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Afinitor (everolimus) and
Afinitor Disperz (everolimus)
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 Specialty:
____________________________
Patient DOB: _______________________________
Physician Phone #:
_____________________________
Date of Rx:
_______________________________
Physician Fax #:
_____________________________
Patient Phone #: ____________________________
Physician Address:
_____________________________
Patient Email Address: ________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
□
Afinitor Disperz (everolimus)
_______________
______________________
Specify: _________________
□
Afinitor tablets (everolimus)
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.
Afinitor Disperz (everolimus)
□
□
Yes
No
Patient has a diagnosis of tuberous sclerosis complex (TSC)
□
□
Yes
No
Patient has subependymal giant cell astrocytoma (SEGA) that requires therapeutic intervention but
cannot be curatively resected (e.g., treated with surgery)
Afinitor tablets (everolimus)
□
□
Yes
No
Patient has a diagnosis of kidney cancer, advanced or metastatic
□
□
No
Patient has a diagnosis of Waldenstrom’s macroglobulinemia (lymphoplasmacytic lymphoma)
Yes
□
□
Yes
No
Patient has a diagnosis of Hodgkin Lymphoma
□
□
Yes
No
Patient has a diagnosis of neuroendocrine tumors
□
□
Yes
No
Patient has a diagnosis of Soft Tissue Sarcoma
□
□
Yes
No
Patient has a diagnosis of Thymomas and Thymic Carcinomas
□
□
Yes
No
Patient has a diagnosis of breast cancer
□
□
Yes
No
Patient is a postmenopausal woman, including medically induced menopause,
with advanced hormone receptor-positive, HER2 negative disease
□
□
Yes
No
Afinitor (everolimus) is being used in combination with an aromatase inhibitor
□
□
Yes
No
Patient has a diagnosis of tuberous sclerosis complex (TSC)
□
□
Yes
No
Patient has subependymal giant cell astrocytoma (SEGA) that requires
therapeutic intervention but cannot be curatively resected (e.g., treated with
surgery)
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Afinitor & Afinitor Disperz NTL PAB Fax Form 07.31.15.doc
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