Express Scripts Prior Authorization Form - Hmg Step Therapy
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1
2Prior Authorization Form
HMG Step Therapy
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 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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Altoprev 20mg
Caduet 10mg-20mg
Lescol 20mg
Vytorin 10mg-10mg
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Altoprev 40mg
Caduet 10mg-40mg
Lescol 40mg
Vytorin 10mg-20mg
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Altoprev 60mg
Caduet 10mg-80mg
Lescol XL 80mg Extended-Release Tab
Vytorin 10mg-40mg
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Caduet 2.5mg-10mg
Crestor 5mg
Livalo 1mg
Vytorin 10mg-80mg
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Caduet 2.5mg-20mg
Crestor 10mg
Livalo 2mg
Zocor 5mg
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Caduet 2.5mg-40mg
Crestor 20mg
Livalo 4mg
Zocor 10mg
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Caduet 5mg-10mg
Crestor 40mg
Mevacor 20mg
Zocor 20mg
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Caduet 5mg-20mg
Lipitor 10mg
Mevacor 40mg
Zocor 40mg
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Zocor 80mg
Caduet 5mg-40mg
Lipitor 20mg
Pravachol 20mg
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Caduet 5mg-80mg
Lipitor 40mg
Pravachol 40mg
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Caduet 10mg-10mg
Lipitor 80mg
Pravachol 80mg
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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?
Yes
No
N/A
2. Is the patient taking samples or paying 100% out of pocket for the medication being requested?
If no, please indicate:
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Requested medication covered under previous insurance plan
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Started medication in hospital
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Other: __________________________________________________________________
HMG Step Therapy: F-14
4.2.2013
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