Read Axert-web-9_27_2002.doc text version

Send completed form to: Service Benefit Plan Prior Approval P.O. Box 52080 MC 139 Additional information is required to process your claim for prescription drugs. Please complete the cardholder portion, and Phoenix, AZ 85072-2080 have the prescribing physician complete the physician portion and submit this completed form. All incomplete and illegible Attn. Clinical Services Fax: 1-800-734-4664 forms will be returned to the patient.

PRIOR APPROVAL REQUEST

CARDHOLDER COMPLETES

Date: ____ / ____ / ____ Cardholder Name: ________________________ / _____ / _________________________________ First MI Last Patient Name: Patient Address: ________________________ / _____ / _________________________________ First MI Last _________________________________________________________________ Street _________________________________________________________________ City State Zip Patient Date of Birth: ____ / ____ / ____ Sex: M ____ F ____

R

Cardholder Identification Number

I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. Authorization is hereby given to any provider of service, which participated in any way in my care, to release to the Blue Cross and/or Blue Shield Plan any medical information which they deem necessary to adjudicate this claim.

(

Cardholder Signature

)

Patient Area Code and Phone Number

PHYSICIAN COMPLETES

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Name of drug to be used:

AXERT ®

FOR INTERNAL USE ONLY

The Blue Cross & Blue Shield Service Benefit Plan does NOT require a Prior Approval Request for a standard allowance. The standard allowance for 6.25mg tablets is 96 tablets total and for 12.5mg tablets is 48 tablets total per 180 days.

Prior Approval is required ONLY in order to EXCEED the standard allowance.

§ § §

Please select from the following strengths:

¬ o 6.25mg tablets

- o 12.5mg tablets

ICD ­ 9 ­ CM codes (mandatory): ______________________________ Diagnosis: _________________________________________________ NOTE: The generalized headache code of 784.0 and/or the diagnosis of "Vascular headache" will not be approved. Please choose an ICD-9 code and diagnosis more descriptive of specific headache type.

The information provided on this form will be used to determine the provision of health care benefits under a U.S. federal government program, and any falsification of records may subject a provider to prosecution, either civilly or criminally, under the False Claim Acts, the False Statements Act, the mail or wire fraud statutes, or other federal or state laws prohibiting such falsification.

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Prescriber Certification: I certify all information provided on this form to be true and correct to the best of my knowledge and belief. I understand that the insurer may request a medical record if the information provided herein is not sufficient to make Frequency of Headaches: ____________ / Month a benefit determination or requires clarification and I Please indicate specific number of additional quantities required for a 180 day period agree to provide any such information to the insurer. 96 tabs + _____ additional tabs/180 days = _____ (total # of 6.25mg tabs) 48 tabs + _____ additional tabs/180 days = _____ (total # of 12.5mg tabs)

6.25mg 12.5mg

WARNING: Contraindicated in patients with ischemic heart disease, Prinzmetal's Angina, uncontrolled hypertension, history of myocardial infarction, or ergotamine use in previous 24 hours. Caution should be exercised in patients in whom unrecognized coronary disease is comparatively likely (males over 40, postmenopausal women, patients with risk factors for CAD, such as hypertension, hypercholesterolemia, obesity, diabetes, smokers, and strong family history).

AX 3035 ­ AXERT ­ WEB Revised 9/27/2002

________________________ ____/____/____ Physician Name (Print Clearly) Date ______________________________________ Street Address ______________________________________ City State Zip ______________________________________ Physician Signature ( ____ ) ___________ // ( ____ ) __________ Phone Fax

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