Catamaran Prior Authorization Department printable pdf download

Catamaran Prior Authorization Department

Phone: 877-228-7909

Fax: 866-511-2202

Caterpillar Prescription Drug Benefit

Prescriber Information

Last Name:

First Name

DEA/NPI:

Specialty:

Phone

Fax

Member Information

Last Name:

First Name

Member ID Number

DOB:

Medication Information:

Drug Name and Strength:

Quantity and Dosing:

__________________________________________________

_______________________________________________

Diagnosis:

Duration:

__________________________________________________

_______________________________________________

When advised below, please include all requested fax documentation (lab results, etc.) when submitting this Prior

Authorization fax form; not submitting requested documentation could delay the clinical review process.

Xifaxan 550 mg Prior Authorization Form

You must answer ALL of the following questions

1. Is the patient 18 years of age or older?

2. What is the patient’s diagnosis? (Please Circle)

•

Hepatic encephalopathy

•

Irritable bowel syndrome with diarrhea

•

Other: _________________________________________________________________________

Hepatic encephalopathy

3. Has the patient tried and had an inadequate response to lactulose?

4. Will Xifaxan be used in combination with lactulose?

5. Does the patient have a medical contraindication to lactulose?

If yes, please submit documentation.

10/26/15

Page 1 of 2

Catamaran Prior Authorization Department