CONTAINS CONFIDENTIAL PATIENT INFORMATION
Oxycontin (oxycodone) 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 #:
Patient DOB: __________________________________
Physician Phone #:
Date of Rx:
Physician Fax #:
Patient Phone #: _______________________________
Patient Email Address: ___________________________
Physician NPI #:
4. STRENGTH □ 10mg □ 15mg □ 30mg □ 40mg □ 80mg
□ Oxycontin (oxycodone)
Physician Email Address: ___________________________ 5. DIRECTIONS 6. QUANTITY PER 30 DAYS
□ 20mg □ 60mg
7. DIAGNOSIS: _______________________________________________________________________________ 8. APPROVAL CRITERIA:
CHECK ALL BOXES THAT APPLY
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
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.
Oxycontin 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.