Form F-11304 - Prior Authorization/preferred Drug List (Pa/pdl) For Cytokine Page 3

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PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL ADHESION MOLECULE
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(CAM) ANTAGONIST DRUGS FOR ANKYLOSING SPONDYLITIS
F-11304 (01/2017)
SECTION III A – ADDITIONAL CLINICAL INFORMATION FOR NON-PREFERRED CYTOKINE AND CAM ANTAGONIST DRUG
REQUESTS (Prior authorization requests for non-preferred cytokine and CAM antagonist drugs must be submitted on
paper.)
19. Indicate the cytokine and CAM antagonist drugs the member has taken and provide specific details regarding the treatment
response. If additional space is needed, continue documentation in Section VI of this form.
Note: A copy of the member’s medical records must be submitted with the PA request to support the condition being
treated, details regarding previous medication use, and outline the member’s current treatment plan.
1. Drug Name
Dose
Dates Taken
Reason for Discontinuation
2. Drug Name
Dose
Dates Taken
Reason for Discontinuation
3. Drug Name
Dose
Dates Taken
Reason for Discontinuation
SECTION IV – AUTHORIZED SIGNATURE
20. SIGNATURE – Prescriber
21. Date Signed
SECTION V – FOR PHARMACY PROVIDERS USING STAT-PA
22. National Drug Code (11 digits)
23. Days’ Supply Requested (Up to 365 Days)
24. NPI
25. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future or up to 14 days
in the past.)
26. Place of Service
27. Assigned PA Number
28. Grant Date
29. Expiration Date
30. Number of Days Approved
SECTION VI – ADDITIONAL INFORMATION
31. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the
product requested may be included here.
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