Form F-11077 - Prior Authorization / Preferred Drug List For Non-Steroidal Anti-Inflammatory Drugs Page 2

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PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS),
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INCLUDING CYCLO-OXYGENASE INHIBITORS
F-11077 (12/12)
SECTION IIIA — CLINICAL INFORMATION FOR CYCLO-OXYGENASE INHIBITORS ONLY
 Yes
14. Does the member have a history of familial adenomatous polyposis (FAP)?
No
15. Does the member have medical record documentation of thrombocytopenia or platelet
 Yes
dysfunction?
No
16. Does the member have medical record documentation of peptic ulcer disease, a history
 Yes
of gastrointestinal (GI) bleeding, or a history of NSAID-induced GI bleeding?
No
 Yes
17. Is the member currently taking oral anticoagulation therapy?
No
18. Has the member been prescribed daily low-dose aspirin for cardioprotection and requires
 Yes
NSAID therapy?
No
 Yes
19. Is the member 65 years of age or older?
No
SECTION IV — FOR PHARMACY PROVIDERS USING STAT-PA
20. National Drug Code (11 Digits)
21. Days’ Supply Requested (Up to 365 Days)
22. NPI
23. 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.)
24. Place of Service
25. Assigned PA Number
26. Grant Date
27. Expiration Date
28. Number of Days Approved
SECTION V — AUTHORIZED SIGNATURE
29. SIGNATURE — Prescriber
30. Date Signed
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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