Medicare Part - D Actiq (Transmucosal Fentanyl Citrate) Prior Authorization Of Benefits (Pab) Form

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Complete Medicare Part - D Actiq (Transmucosal Fentanyl Citrate) Prior Authorization Of Benefits (Pab) Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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To initiate your request immediately, please call the

Prior Authorization of Benefits Center at (800) 338-6180

To submit your request via fax, complete this form in its entirety and fax to:

Prior Authorization of Benefits Center at (800) 601- 4829

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Medicare Part - D

Actiq (transmucosal fentanyl citrate)

Prior Authorization of Benefits (PAB) Form

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:

___________________________

Physician DEA:

___________________________

Patient Email Address: _________________________

Physician NPI #:

___________________________

Physician Email Address: ________________________

3. MEDICATION

4. STRENGTH

5. DIRECTIONS

6. QUANTITY PER 30 DAYS

Actiq (fentanyl)

__________________

______________________

Specify: _________________

CHECK ALL BOXES THAT APPLY

7. APPROVAL CRITERIA:

NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.

What is the patient’s diagnosis? ______________________________________________________________________

What other medications has the patient tried for this diagnosis?

1. __________________________ Dates: ________________________ Outcome: ______________________________

2. __________________________ Dates: ________________________ Outcome: ______________________________

3. __________________________ Dates: ________________________ Outcome: ______________________________

□

Yes

Patient has previously tried and failed two formulary products: one of which is in the SAME specific

drug class; the other product can be in a DIFFERENT drug class; HOWEVER, it must have the

SAME indication as the product requested

□

Yes

Patient has a documented drug-drug interaction with formulary products

□

Yes

Patient has a documented drug-disease interaction with formulary products

If yes, please list the specific drug-drug or drug-disease interaction(s) below:

_______________________________________________________________________________

8. 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 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.

Med D Actiq PAB Fax Form 01.11.16.doc