Express Scripts Prior Authorization Form - Antihistamines Step Therapy
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1
2Prior Authorization Form
Antihistamines 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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Allegra 30mg Tablet
Allegra 12-Hour Tablet
Clarinex RediTabs 5mg
Zyrtec 5mg Chewable Tablet
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Allegra 30mg/5ml
Allegra-D 12-Hour Tablet
Orally Disintegrating Tablet
Zyrtec 10mg Chewable Tablet
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Suspension
Allegra-D 24-Hour Tablet
Clarinex-D 12 Hour
Zyrtec 10mg Liquid Gel Capsule
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Allegra 60mg Tablet
Clarinex 5mg
Clarinex-D 24 Hour
Zyrtec 1mg/ml Syrup
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Allegra 60mg Capsule
Clarinex 0.5mg/ml Syrup
Xyzal 5mg
Zyrtec-D 12 Hour 5mg-120mg ER
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Allegra 180mg Capsule
Clarinex RediTabs 2.5mg
Xyzal 2.5mg/5ml Solution
Other: ___________________
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Allegra ODT 30mg
Orally Disintegrating Tablet
Zyrtec 5mg Tablet
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, for how long? ________________________________________________________
Yes
No
2. Is the patient taking samples or paying 100% out of pocket for the medication being
requested?
Yes
No
3. Was the patient on the requested drug on a previous occasion?
Antihistamines Step Therapy F14
5.17.2013
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