Form Rx018 - Prior Authorization Request Form For Celebrex (Celecoxib)

FORM # FRX018

Prior Authorization Request Form for Celebrex (celecoxib)

Member Information

Provider Information

Patient Name ____________________________

Provider Name ____________________________

Cardholder ID ___________________________

DEA Number _____________________________

Date of Birth ____________________________

Address __________________________________

Address ________________________________

City, State and Zip _________________________

City, State Zip ___________________________

Phone Number ____________________________

Phone Number ___________________________

FAX Number _____________________________

Pharmacy Information

Pharmacy Name___________________Address__________________Phone______________________

Criteria for Approval:

□

□

1. Celebrex

100mg

200mg

2. Is the patient between 18 years of age and 60 years of age?

Yes

No

3. Is the patient 60 years of age or older?

Yes

No

4. Does the patient have any of the following diagnoses? Check all that apply:

Familial adenomatous polyposis (FAP)

Primary dysmenorrhea

Acute pain

Osteoarthritis

Rheumatoid arthritis

5. Is the patient at high risk for NSAID-induced gastrointestinal (GI) adverse events? Yes

No

6. Is the patient currently on a proton pump inhibitor?

Yes

No

7. Is the patient currently on aspirin therapy?

Yes

No

8. Has the patient experience any allergic reaction to taking any of the following?

Check all that apply:

Aspirin

NSAIDs

Sulfonamides

Provider Signature _________________________________________ Date _______________________

Fax completed forms to (866) 284-4509.

For Office Use Only

Date/Time Received_____________________________________________________________________

Reference Number______________________________________________________________________

Approved / Denied (Circle One) by _____________________________ Date_______________________

Date/Time Returned to Provider___________________________________________________________

_____________________________________________________________________________________

If you have any questions regarding this form, contact the Prior Authorization Department Toll Free at

(866) 284-4492 or Fax Toll Free at (866) 284-4509.

FOX Rx Care Utilization Management

3375-I Capital Circle NE

Tallahassee, FL 32308

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