Catamaran Prior Authorization Department (Page 2 of 2) in pdf

Catamaran Prior Authorization Department Page 2

Catamaran Prior Authorization Department

Phone: 877-228-7909

Fax: 866-511-2202

Caterpillar Prescription Drug Benefit

Xifaxan 200 mg Prior Authorization Form

You must answer ALL of the following questions

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

•

Traveller’s diarrhea

•

C. difficile colitis

•

Hepatic encephalopathy

•

Other: __________________________________________________________________________

C. difficile colitis

2. Do lab results show that the toxin is present?

Please provide supporting lab results.

Note: Lab results must show toxin is present, and not just a positive culture for C. difficile.

Please note, not all drugs/diagnoses are covered on all plans.

Comments: ________________________________________________________________________________________

Information given on this form is accurate as of this date.

Caterpillar Prior Authorization forms are located at on the “For Providers” tab. Print a new form

for each request as forms are updated periodically.

__________________________________________________________

_________________________

Prescriber or Authorized Signature

Date

__________________________________________________________

Authorized Medical Staff – Name/Title

Attention Healthcare Provider: If you would like to discuss this request with a medical professional, please contact

the Prior Authorization Department at 800-626-0072.

I understand that Catamaran’s use or disclosure of individually identifiable health information, whether furnished by

me or obtained by another source such as medical providers, shall be in accordance with federal privacy regulations

under HIPAA (Health Insurance Portability and Accountability Act of 1996).

10/26/15

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Catamaran Prior Authorization Department Page 2