Form 6375 Ks Nepr 0116 - Neprilysin Inhibitor Prior Authorization

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NEPRILYSIN INHIBITOR(ENTRESTO™)

PRIOR AUTHORIZATION

Clear Data

Physician Fax Form

BCBS Kansas REQUIRES that this form be completed by the prescriber. This form is for prospective, concurrent and retrospective reviews.

The following documentation is REQUIRED for prior authorization. Incomplete forms will be returned for additional information.

To ensure you are submitting this form correctly, you can complete and submit it directly to us online at

For formulary information, please visit the Blue Cross and Blue Shield of Kansas website at

PATIENT INFORMATION

Today’s Date:

Patient Name (First):

Last:

DOB (mm/dd/yyyy):

Patient Address:

City, State, Zip:

Patient Telephone:

INSURANCE INFORMATION

Member ID Number:

Group Number:

PHYSICIAN/CLINIC INFORMATION

Prescriber Name:

Physician NPI#:

Specialty:

Contact Name:

Clinic Name:

Clinic Address:

City, State, Zip:

Phone #:

Secure Fax #:

(PA decisions will be sent here)

PLEASE ATTACH ANY ADDITIONAL INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST

Patient Diagnosis

– ICD code plus description:

Medication Requested:

Strength

Dosing Schedule:

Quantity per Month:

Does the patient have NYHA Class II – IV heart failure? ........................................................................................

Yes

What is the baseline or current left ventricular ejection fraction: _____________________________________

Is the patient currently on a beta blocker? .............................................................................................................

Yes

If no, does the patient have an intolerance or contraindication to a beta blocker? ........................................

Yes

If yes, please explain: _____________________________________________________________

Will the patient be taking Entresto in combination with an ACE inhibitor or aliskerin? ............................................

Yes

Does the patient have a history of angioedema related to previous ACE inhibitor or ARB therapy? ......................

Yes

Is the patient pregnant? ..........................................................................................................................................

Yes

Please list all reasons for selecting the requested medication, strength, and quantity over alternatives (e.g. contraindications,

allergies or history of adverse drug reactions to alternatives, lower dose has been tried):

Please list all other medications the patient is currently taking for treatment of this diagnosis.

Please list all medications the patient has previously tried and failed for treatment of this diagnosis. (Please specify if the

patient has tried brand-name products, generic products or over-the-counter products.)

____________________________

Date: ___________

___________________________

Date: __________

___________________________

Date: ___________