Ruconest (C1 Esterase Inhibitor [recombinant]) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Ruconest (C1 esterase inhibitor [recombinant])

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

Ruconest (C1 esterase

________________

______________________

Specify: _________________

inhibitor [recombinant])

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 Hereditary Angioedema (HAE)

□

□

Yes

No

Diagnosis was confirmed by a C4 level below the lower limit of normal as defined by the laboratory

performing the test AND ONE of the following (please indicate):

□ C1 inhibitor (C1-INH) antigenic level below the lower limit of normal as defined by the laboratory

performing the test

□ C1-INH functional level below the lower limit of normal as defined by the laboratory performing the test

□

□

Yes

No

Patient has a history of moderate or severe attacks (for example, airway swelling, severe abdominal

pain, facial swelling, nausea and vomiting, painful facial distortion)

□

□

Yes

No

Ruconest (C1 esterase inhibitor [recombinant]) is being used for treatment of acute HAE attacks (not for

prophylaxis or in individuals with laryngeal attacks)

□

□

Yes

No

Patient is 13 years of age or older

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.

Ruconest NTL PAB Fax Form 12.19.14.doc