Ragwitek (Short Ragweed Pollen Allergen Extract) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Ragwitek (short ragweed pollen allergen extract)

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

Ragwitek (short ragweed pollen

_________________

______________________

Specify: _________________

allergen extract)

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 short ragweed pollen-induced allergic rhinitis

□

□

Yes

No

Diagnosis has been documented by one of the following:

□

Positive skin test

□

Positive in vitro testing for pollen-specific IgE antibodies for short ragweed pollen

□

□

Yes

No

Patient has had a trial of and inadequate symptom control with one nasal steroid and one non-

sedating antihistamine

□

□

Yes

No

Patient has a documented prescription for an auto-injectable epinephrine product

□

□

Yes

No

Treatment will be initiated at least 12 weeks before the expected onset of ragweed pollen season

and continued throughout the season

□

□

Yes

No

Patient is between the ages of 18 and 65 years old

□

□

Yes

No

Patient has severe, unstable or uncontrolled asthma

□

□

Yes

No

Patient has a history of any severe systemic allergic reaction

□

□

Yes

No

Patient has a history of eosinophilic esophagitis

□

□

Yes

No

Patient is receiving therapy with other allergen immunotherapy products at the same time

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.

Ragwitek NTL PAB Fax Form 07.11.14.doc