Non Formulary Exceptions & Multi-Source Brand Medications Prior Authorization Of Benefits (Pab) Form
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2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Non Formulary Exceptions &
Multi-Source Brand Medications
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
__________________
_________________ _______________
: ________________
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.
Non Formulary Exceptions:
□
□
Yes
No
Patient has previously tried and failed 2 (two) preferred products: One of which is in the same
specific drug class; the other product has the same indication as the product requested
If yes, please indicate trials below
□
□
Yes
No
For combination products: patient has tried 2 (two) preferred products: One of which is in the same
specific class as at least one ingredient in the requested medication
If yes, please indicate trials below
□
□
Yes
No
For non-preferred antibiotics/ anti-virals/ anti-fungals: patient has tried and failed on preferred
antibiotic/ anti-viral/ anti-fungal product within the same route of administration
If yes, please indicate trial below
□
□
Yes
No
Patient has a documented drug interaction
□
□
Yes
No
Patient has documented adverse drug experiences (side effects, adverse drug reaction)
Product 1: ________________________________________ Dates Tried: ____________________________________
Product 2: ________________________________________ Dates Tried: ____________________________________
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CONTINUED ON PAGE 2
Non Formulary Exceptions & Multi-Source Brand Medications HIX PAB Fax Form 09.15.14.doc
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