Read CelebrexPriorAuth.pdf text version

Celebrex Step Therapy

PHYSICIAN PRIOR AUTHORIZATION REQUEST FORM

BlueChoice® HealthPlan Patient Information

Name: Address: Insurance ID #: Birthdate:

Provider Information

Physician's Name: Phone: Office Address: Diagnosis: ICD-9 Code: Physician DEA #: Fax:

When this form is completed, please fax back to Caremark at 888-836-0730.

This fax machine is located in a HIPAA-compliant secure location. Call Caremark at 800-294-5979 with any questions concerning prior authorization procedures. On behalf of BlueChoice HealthPlan, Caremark assists in the administration of this program. Caremark is an independent company that administers prescription drug benefits. 1. Has the patient experienced severe allergic-type reactions after taking aspirin or another NSAID? 2. Has the patient experienced severe allergic-type reactions after taking sulfonamides? 3. Is the patient at high risk (e.g., >10% 10 year CV event risk by history or cardiac workup) for cardiovascular disease or does the patient have pre-existing cardiovascular disease? 4. Is the patient being treated for post-operative pain following CABG surgery? 5. Does the patient have a diagnosis of familial adenomatous polyposis (FAP)? [If answer to this question is no, then skip to question 7.] 6. Will Celebrex be added as an adjunct therapy to the usual care for colorectal polyps? [No further questions.] 7. Does the patient have a diagnosis of rheumatoid arthritis? [If the answer to this question is yes, then skip to question 12.] 8. Does the patient have the diagnosis of juvenile rheumatoid arthritis? [If the answer to this question is yes, then skip to question 12.] 9. Does the patient have the diagnosis of ankylosing spondylitis? [If the answer to this question is yes, then skip to question 12.] 10. Does the patient have a diagnosis of primary dysmenorrhea? [If the answer to this question is yes, then skip to question 12.] Confidential Page 1 of 2

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.

Y Y Y Y Y Y Y Y Y Y

N N N N N N N N N N

Effective: 2/18/2010

CELEBREX STEP THERAPY

PHYSICIAN PRIOR AUTHORIZATION REQUEST FORM

BlueChoice® HealthPlan

11. Does the patient have a diagnosis of acute pain? 12. Is the patient at risk for a severe NSAID-related gastrointestinal (GI) adverse event such as an NSAID associated gastric ulcer or gastrointestinal bleeding? (Risk factors may include: age 60 or older, prior history of GI events (e.g., peptic ulcer, GI bleed, GERD, S/P gastrectomy, gastritis) or thrombocytopenia or coagulation disorders or concomitant use of corticosteroids or anticoagulants, Plavix, or chemotherapy or long term/multiple NSAID use.) Y N

Y

N

Comments: _______________________________________________________________________________________

Information on this form is accurate as of the date below. Prescriber's Signature:

Date:

Confidential

Page 2 of 2

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.

Effective: 2/18/2010

Information

2 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

38966


You might also be interested in

BETA
Microsoft Word - Nuvigil Web Prior Auth Req Form lhrev.doc