Prior Authorization / Brand Medically Necessary Attachment Page 2
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2PRIOR AUTHORIZATION / BRAND MEDICALLY NECESSARY ATTACHMENT (PA/BMNA)
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F-11083 (01/15)
SECTION III — CLINICAL INFORMATION (Continued)
15. Has the member experienced an unsatisfactory therapeutic response or clinically
significant adverse drug reaction with at least two different manufacturers of the
generic equivalent drug?
Yes
No
If yes, list the manufacturer or National Drug Code (NDC), dates taken, and indicate the specific details about the unsatisfactory
therapeutic response(s) or clinically significant adverse drug reaction(s) that can be directly attributed to the generic equivalent
drugs.
Manufacturer / NDC
Dates Taken
Indicate in the space provided the specific details about the unsatisfactory therapeutic response or clinically significant adverse drug
reaction that can be directly attributed to this generic drug.
Manufacturer / NDC
Dates Taken
Indicate in the space provided the specific details about the unsatisfactory therapeutic response or clinically significant adverse drug
reaction that can be directly attributed to this generic drug.
Manufacturer / NDC
Dates Taken
Indicate in the space provided the specific details about the unsatisfactory therapeutic response or clinically significant adverse drug
reaction that can be directly attributed to this generic drug.
Manufacturer / NDC
Dates Taken
Indicate in the space provided the specific details about the unsatisfactory therapeutic response or clinically significant adverse drug
reaction that can be directly attributed to this generic drug.
Note: Pharmacy providers may provide manufacturer or NDC and dates taken.
16. Explain how the BMN drug will prevent the recurrence of the unsatisfactory therapeutic response or clinically significant adverse
drug reaction described in Element 15.
17. Has the member taken the requested brand name drug and had a measurable
therapeutic response?
Yes
No
If yes, indicate the approximate dates the brand name drug was taken.
SECTION IV — AUTHORIZED SIGNATURE
18. SIGNATURE — Prescriber
19. Date Signed
SECTION V — ADDITIONAL INFORMATION
20. Additional diagnostic and clinical information explaining the need for the drug required may be included below.
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