Lazanda Nasal Spray (Fentanyl Citrate) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Lazanda Nasal Spray (fentanyl citrate)

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

Lazanda Nasal Spray (fentanyl citrate)

____________

______________________

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.

□

□

Yes

No

Patient has a diagnosis of cancer with breakthrough cancer pain

□

□

Yes

No

Patient is already receiving opioids and is tolerant to opioid therapy defined as receiving around the

clock medicine consisting of one of the following (please indicate):

□

at least 60mg oral morphine daily

□

at least 25mcg transdermal fentanyl/hour

□

at least 30mg oral oxycodone daily

□

at least 8mg oral hydromorphone daily

□

at least 25mg oral oxymorphone daily

□

an equianalgesic dose of another opioid for a week or longer

□

□

Yes

No

Patient is continuing around the clock opioids while taking Lazanda

□

□

Yes

No

Patient has had a trial of generic fentanyl citrate (Actiq)

□

□

Yes

No

Patient has completed titration and is maintained on a stable dose of Lazanda

□

□

Yes

No

Patient is 18 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.

Lazanda Nasal Spray NTL PAB Fax Form 08.28.15.doc