Actiq (Fentanyl) Quantity Supply Prior Authorization Of Benefits (Pab) Form

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CONTAINS CONFIDENTIAL PATIENT INFORMATION

Actiq (fentanyl) Quantity Supply

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

□

200mcg

400mcg

600mcg

□

______________________

Specify: _________________

Actiq (fentanyl)

□

800mcg

1200mcg

1600mcg

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.

□

Cancer Diagnosis

□

Other ______________________________________________________________________________________

____________________________________________________________________________________________

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.

Actiq Quantity Supply NTL PAB Fax Form 03.28.11.doc

Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.