Hysingla Er (Hydrocodone Bitartrate Extended Release) Prior Authorization Of Benefits (Pab) Form
ADVERTISEMENT
1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Hysingla ER (hydrocodone bitartrate
extended release)
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
Hysingla ER (hydrocodone
________________
______________________
Specify: _________________
bitartrate extended release)
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 pain severe enough to require daily, around-the-clock, long term opioid
treatment
□
□
Yes
No
Patient had an inadequate response to alternative treatment options, such as but not limited to non-
opioid analgesics and immediate-release opioids
□
□
Yes
No
Alternative treatment options would otherwise be inadequate to provide sufficient management of
pain
□
□
Yes
No
Patient has had a trial of any two of the following generic long acting agents in the previous 180
days:
□
□
Fentanyl Patch
Levorphanol
□
□
Methadone
Methadose
□
□
Morphine Sulfate ER (MS Contin
Tramadol ER (Ultram ER)
□
□
Oxymorphone ER (Opana ER)
Hydromorphone ER
□
□
Yes
No
Patient has completed titration and is already maintained on a stable dose of Hysingla ER
(hydrocodone bitartrate extended release)
□
□
Yes
No
Patient is requesting or using Hysingla ER (hydrocodone bitartrate extended‐release) as an as-
needed analgesic
□
□
Yes
No
Patient has one of the following conditions (please indicate):
□
□
Yes
No
Significant respiratory depression
□
□
Yes
No
Acute or severe bronchial asthma or hypercarbia
□
□
Yes
No
Known or suspected paralytic ileus
□
□
Yes
No
Patient is 18 years of age or older
PAGE 1 OF 2
CONTINUED ON PAGE 2
Hysingla ER NTL PAB Fax Form 12.15.15.doc
ADVERTISEMENT
0 votes
Related Articles
Related forms
Zohydro Er (hydrocodone Bitartrate Extended-release) Prior Authorization Of Benefits (pab) Form
Business
Xigduo Xr (dapagliflozin/metformin Extended-release) Prior Authorization Of Benefits (pab) Form
Business
Xigduo Xr (dapagliflozin/metformin Extended-release) Prior Authorization Of Benefits (pab) Form
Business
Related Categories
Parent category: Business