Benzaclin Gel (Benzoyl Peroxide/clindamycin) Benzaclin Care Kit (Benzoyl Peroxide/clindamycin W/ Hyaluronate Sodium) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

BenzaClin Gel (benzoyl peroxide/clindamycin)

BenzaClin Care Kit (benzoyl

peroxide/clindamycin w/ hyaluronate 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

□

□

BenzaClin Gel (benzoyl

5% benzoyl peroxide /

peroxide/clindamycin)

1% clindamycin gel

□

□

BenzaClin Gel w/ pump

5% benzoyl peroxide /

(benzoyl

1% clindamycin gel

______________________

Specify: _________________

peroxide/clindamycin)

□

□

BenzaClin Care Kit

5% benzoyl peroxide /

(benzoyl

1% clindamycin w/

peroxide/clindamycin w/

hyaluronate sodium

hyaluronate sodium)

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 had a trial and inadequate response or intolerance to one preferred generic topical anti-

infective/benzoyl peroxide combination agent (benzoyl peroxide/erythromycin gel or benzoyl

peroxide/clindamycin topical gel)

□

□

Yes

No

Patient has had a trial and inadequate response or intolerance to one preferred brand topical anti-

infective/benzoyl peroxide combination agent [Duac (benzoyl peroxide/clindamycin) or Duac CS Kit

(benzoyl peroxide/clindamycin)]

□

□

Yes

No

The preferred agents are unacceptable due to concomitant clinical conditions, such as but not limited

to a known disease state or medication contraindication which is not also associated with the

requested agent

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.

BenzaClin NTL PAB Fax From 09.04.15.doc