Express Scripts Prior Authorization Form - Brand Nsaid Step Therapy
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1
2Prior Authorization Form
Brand NSAID Step Therapy
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-328-9799
applicable to all patients; certain plans and situations may require additional
information beyond what is specifically requested.
If this an URGENT request, please call 1-800-753-2851
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 drug and strength is being requested:
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Orudis 25mg
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Anaprox 275mg
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Lodine 300mg
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Orudis 50mg
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Anaprox DS 550mg
Lodine 400mg
□
Orudis 75mg
□
Ansaid 50mg
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Lodine 500mg
□
Oruvail 100mg
□
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Ansaid 100mg
Lodine XL 400mg
□
Oruvail 150mg
□
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Arthrotec 50
Lodine XL 500mg
□
Oruvail 200mg
□
Arthrotec 75
□
Lodine XL 600mg
□
Pennsaid 1.5% Topical Solution
□
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Cambia Powder
Mobic 7.5mg
□
Ponstel 250mg
□
Cataflam 50mg
□
Mobic 15mg
□
Prevacid Naprapac 375mg
□
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Clinoril 150mg
Mobic 7.5mg/5ml Suspension
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Prevacid Naprapac 500mg
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Clinoril 200mg
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Motrin 100mg/5ml Suspension
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Relafen 500mg
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Daypro 600mg
Motrin 200mg
□
Relafen 750mg
□
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Daypro ALTA 600mg
Motrin 400mg
□
Sprix 15.75mg/actuation Nasal Spray
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EC-Naprosyn 375mg
□
Motrin 600mg
□
Toradol 15mg/ml Injection
□
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EC-Naprosyn 500mg
Motrin 800mg
□
Toradol 30mg/ml Injection
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Feldene 10mg
□
Nalfon 200mg
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Toradol 10mg Tablet
□
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Feldene 20mg
Nalfon 300mg
□
Vimovo 375mg-20mg Delayed Release Tab
□
Flector 1.3% Topical Patch
□
Nalfon 400mg
□
Vimovo 500mg-20mg Delayed Release Tab
□
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IC400 Kit
Naprelan 375mg
□
Voltaren 1% Topical Gel
□
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IC800 Kit
Naprelan 500mg
□
Voltaren 25mg Tablet
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Indocin 25mg
□
Naprelan 750mg
□
Voltaren 50mg Tablet
□
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Indocin 50mg
Naprelan CR Dose Card
□
Voltaren 75mg Tablet
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Indocin 25mg/5ml Suspension
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Naprosyn 250mg
□
Voltaren-XR 100mg Tablet
□
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Indocin SR 75mg
Naprosyn 375mg
□
Zipsor 25mg
□
Lodine 200mg
□
Naprosyn 500mg
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Other:______________________________
Directions for use (i.e. QD, BID, PRN & Qty): _______________________________________________________________________
Please complete the clinical assessment:
Yes
No
N/A
1. Is the patient currently taking the requested medication?
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