CONTAINS CONFIDENTIAL PATIENT INFORMATION
Prevacid (lansoprazole)
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 #:
__________________________________
Physician Address:
_____________________________
Patient DOB: __________________________________
Physician Phone #:
_____________________________
Date of Rx:
Physician Fax #:
_____________________________
Patient Phone #: _______________________________
Physician Specialty:
____________________________
Patient Email Address: ___________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
__________________________________
3. MEDICATION
□ Prevacid (lansoprazole)
□ Prevacid SoluTab (lansoprazole ODT)
4. STRENGTH
Physician Email Address: ___________________________
5. DIRECTIONS
6. QUANTITY per 30 days
___________
__________________________
_______________________
7. DIAGNOSIS: ______________________________________________________________________________________
8. CLINICAL INFORMATION - NOTE: Any areas not filled out are considered not applicable to your patient & MAY
AFFECT THE OUTCOME of this request.
Please indicate patient’s age: _______
□ Yes
□ No
Patient is currently taking Plavix (clopidogrel)
□ Yes □ No IF TAKING PLAVIX (clopidogrel), patient has had a trial of, and inadequate response or
intolerance to, the Preferred proton pump inhibitors (PPIs) (lansoprazole and
pantoprazole)
□ Yes □ No IF NOT TAKING PLAVIX (clopidogrel), patient has had a trial of, and inadequate
response or intolerance to, four of the Preferred PPIs (lansoprazole, omeprazole,
pantoprazole, omeprazole/sodium bicarbonate capsules, Nexium Suspension)
□ Yes
□ Yes
□ No
□ No
The preferred PPIs are FDA-approved for the prescribed indication
The preferred PPIs are unacceptable due to concomitant clinical situations, such as but not limited to a
known disease state or medications contraindications which is not also associated with the requested
product (for example inability to swallow tablets/capsules or age)
Quantity Limits - Proton pump inhibitors are limited to 1 dose per day [1 cap/tab/pkt per day]
Requests for increased quantity please answer the following:
Increased Dosing up to 2 doses/day may be approved if the following apply:
□ Yes □ No Patient tried once a day dosing [for 30 days], failed, and needs twice a day dosing
□ Yes □ No Patient has been diagnosed with eosinophilic esophagitis
Increased Dosing of 2 per day for 14 days may be approved if the following diagnosis applies:
□ Yes □ No H. pylori, for eradication
Increased Dosing beyond 2 doses/day may be approved if the following diagnosis apply:
□ Yes □ No Hypersecretory syndrome (Zollinger-Ellison syndrome, multiple endocrine adenomas, or systemic
Mastocytosis)
□ Yes □ No Barrett’s Esophagus
□ Yes □ No Laryngeal, esophageal or gastric cancer
□ Yes □ No Scleroderma or limited scleroderma (CREST syndrome)
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Prevacid NTL PAB Fax Form 10.01.15.doc
CONTAINS CONFIDENTIAL PATIENT INFORMATION
Prevacid (lansoprazole)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
Patient Name: ___________________________________
Patient ID#: __________________________________
9. PHYSICIAN SIGNATURE
____________________________________________________________
__________________________________________
Prescriber or Authorized Signature
Date
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
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Prevacid NTL PAB Fax Form 10.01.15.doc