Express Scripts Prior Authorization Celebrex
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1
2Prior Authorization Form
Celebrex
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-800-357-9577
applicable to all patients; certain plans and situations may require
additional information beyond what is specifically requested.
If this an URGENT request, please call 1-800-417-8164
Additional forms available:
Patient Information
Prescriber Information
Patient First Name: ______________________________
Prescriber Name: _________________________________
Prescriber DEA/NPI (required): ______________________
Patient Last Name: _______________________________
Prescriber Phone #: _______________________________
Patient ID#: _____________________________________
Prescriber Fax #: _________________________________
Patient DOB: ____________________________________
Prescriber Address: _______________________________
Patient Phone #: _________________________________
State: ________________ Zip Code: __________________
Primary Diagnosis: _________________________________ ICD Code: ________________________________________
Please indicate which strength of Celebrex is being requested:
□
□
□
□
Celebrex 200mg
Celebrex 400mg
Celebrex 50mg
Celebrex 100mg
Directions for use (i.e. QD, BID, PRN & Qty): __________________________________________________________________________
Please complete the clinical assessment:
Yes
No
1. Is the patient currently taking the requested medication?
Yes
No
2. Is the patient taking samples or paying 100% out of pocket for the medication being requested?
If no, please indicate:
□
Requested medication covered under previous insurance plan
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Started medication in hospital
□
Other: ___________________________________________________________________
Yes
No
3. Has the patient tried 2 oral prescription-strength NSAIDs (may be brand or generic) for the
current condition?
4. Please list the oral prescription-strength NSAIDs (may be brand or generic) the patient has tried for the current condition. Please
include the strength and directions for use: ________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Yes
No
5. Is the patient currently receiving chronic systemic corticosteroid therapy (e.g., prednisone),
warfarin (Coumadin), clopidogrel (Plavix), dabigatran (Pradaxa), ticagrelor (Brilinta),
rivaroxaban (Xarelto), Effient (prasugrel), chronic aspirin therapy, or low-molecular weight
heparin (e.g., fondaparinux (Arixtra), tinzaparin (Innohep), enoxaparin (Lovenox), dalteparin
(Fragmin))?
Yes
No
6. Is Celebrex being used to treat a chronic condition?
Celebrex
9.4.2013
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