Express Scripts Prior Authorization Form - Antidepressant Step Therapy-Bupropion
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2Prior Authorization Form
Antidepressant Step Therapy-Bupropion
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-329-3760
applicable to all patients; certain plans and situations may require
If this an URGENT request, please call at 1-800-753-2851
additional information beyond what is specifically requested.
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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Aplenzin 174mg
Wellbutrin SR 100mg
Forfivo XL 450mg
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□
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Wellbutrin XL 150mg
Aplenzin 348mg
Wellbutrin SR 150mg
□
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Aplenzin 522mg
Wellbutrin SR 200mg
Wellbutrin XL 300mg
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Other: _____________________________
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?
If yes, how long has the patient been taking the 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
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Other: ___________________________________________________________________
Yes
No
3. Has the patient tried a generic bupropion sustained-release or generic extended-release tablet?
If yes, please indicate:
□
□
Budeprion XL
Bupropion extended-release tablets
□
□
Budeprion SR
Bupropion sustained-release tablets
□
Other: __________________________________
________________________________________
Antidepressant Step Therapy-Bupropion: F-14
4.2.2013
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