Xigduo Xr (Dapagliflozin/metformin Extended-Release) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Actimmune (interferon gamma-1b)

Prior Authorization of Benefits (PAB) Form

Complete form in its entirety and fax to:

Prior Authorization of Benefits Center at (800) 601- 4829

1. PATIENT INFORMATION

2. PHYSICIAN INFORMATION

Patient Name: _______________________________

Prescribing Physician: _________________________

Patient ID #:

_______________________________

Physician Address:

_________________________

Patient DOB: _______________________________

Physician Phone #:

_________________________

Date of Rx:

_______________________________

Physician Fax #:

_________________________

Patient Phone #. _____________________________

Physician Specialty:

_________________________

Patient Email Address: ________________________

Physician DEA:

_________________________

Physician NPI #:

_________________________

Physician Email Address: ______________________

3. MEDICATION

4. STRENGTH

5. DIRECTIONS

6. QUANTITY PER 30 DAYS

Actimmune (interferon gamma-1b)

_____________

______________________

Specify: _________________

7. DIAGNOSIS: ___________________________________________________________________________________

CHECK ALL BOXES THAT APPLY

8 APPROVAL CRITERIA:

NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.

□

□

Yes

No

Patient has a diagnosis of Chronic Granulomatous Disease

□

□

Yes

No

Patient has a diagnosis of Severe, malignant osteopetrosis

□

□

Patient has a diagnosis of Non-Hodgkin Lymphoma (NHL) – Mycosis fungoides/ Sezary Syndrome

Yes

No

9 PHYSICIAN SIGNATURE

____________________________________________________________

__________________________________________

Prescriber or Authorized Signature

Date

Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what

medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting

provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.

Note: Payment is subject to member eligibility. Authorization does not guarantee payment.

The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only

for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other

party unless required to do so by law or regulation.

If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of

these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or

destruction of these documents.

Actimmune NTL PAB Fax Form 03.10.15.doc