Flolan (Epoprostenol Sodium) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Flolan (epoprostenol sodium)

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 Specialty:

____________________________

Patient DOB: _______________________________

Physician Phone #:

_____________________________

Date of Rx:

_______________________________

Physician Fax #:

_____________________________

Patient Phone #: ____________________________

Physician Address:

_____________________________

Patient Email Address: ________________________

Physician DEA:

____________________________

Physician NPI #:

_____________________________

Physician Email Address: ___________________________

3. MEDICATION

4. STRENGTH

5. DIRECTIONS

6. QUANTITY PER 30 DAYS

□

□

□

____________________

Specify: _________________

Flolan (epoprostenol sodium)

0.5mg

1.5mg

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

Flolan (epoprostenol sodium) will be used as continuous intravenous infusion

□

□

Yes

No

Individual has a diagnosis of Pulmonary Arterial Hypertension (PAH)

□

□

Yes

No

Right heart catheterization shows a mean pulmonary artery pressure (mPAP) greater than 25 mm Hg

□

□

Yes

No

Pulmonary capillary wedge pressure (PCWP), left atrial pressure, or left ventricular end-diastolic

pressure (LVEDP) is less than or equal to 15 mm Hg

□

□

Yes

No

Pulmonary vascular resistance (PVR) is greater than 3 Wood units

□

□

Yes

No

Individual has demonstrated an unfavorable acute response to vasodilators

□

□

Yes

No

Individual has World Health Organization (WHO) Group I idiopathic pulmonary arterial hypertension

including all subtypes of WHO Group I PAH

□

□

Yes

No

Individual has pulmonary hypertension associated with connective tissue disorders (e.g. scleroderma,

systemic sclerosis, etc.)

□

□

Yes

No

Individual has pulmonary hypertension associated with congenital heart defects

□

□

Yes

No

Individual has severe pulmonary arterial hypertension refractory to medical therapy with calcium

channel blockers

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.

Flolan NTL PAB Fax Form 4.13.11.doc

Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.