Form Frx014 - Prior Authorization Request - Alzheimer'S Type Dementia Razadyne(Reminyl)/aricept/namenda/exelon

FORM # FRX014

Prior Authorization Request Form for Alzheimer’s Type Dementia

Razadyne(Reminyl)/Aricept/Namenda/Exelon

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_________________________

Name and strength of drug being requested:___________________________________________

Criteria for Approval:

1. Does the patient have a diagnosis of Alzheimer’s type dementia?

Yes

No

2. The Alzheimer’s dementia can be classified as (Check One):

Mild

Moderate

Severe

3. Has the patient been on the drug being requested for the previous 6 months?

Yes

No

4. Has the patient been evaluated with the Mini-Mental State Exam (MMSE)

for cognitive status assessment for

cognitive status assessment within the previous 3-6 months?

Yes

No

5. Has the rate of cognitive status deterioration further declined since initial treatment or since the Mini-Mental

State Exam?

Yes

No

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 -1 Capital Circle NE

Tallahassee, FL 32308

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