Microsoft word - sildenafil pab fax form 06.20.07.doc

CONTAINS CONFIDENTIAL PATIENT INFORMATION
Revatio® & Viagra® (sildenafil)
Complete form in its entirety and fax to:
Prior Authorization of Benefits (PAB) Center at (888) 831- 2243
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: _________________________ Physician DEA: _________________________ 3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
**NOTE: QL – Specific to members EOC
7. 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.
Erectile Dysfunction:
□ Yes □ No Patient is male? AND
□ Yes □ No Patient has a documented diagnosis of erectile dysfunction? AND
□ Yes □ No Is the patient on concurrent nitrate therapy?
Recommendations:
1. Physician should advise patients to stop use of all PDE-5 inhibitors and seek medical attention in the event of a sudden loss of vision in one or both eyes. Such an event may be a sign of non-arteritic anterior ischemic optic neuropathy (NAION), a cause of decreased vision, which can result in permanent loss of vision. 2. Physicians should discuss with patients the increased risk of NAION in individuals who have already experienced NAION in one eye, including whether such individuals could be adversely affected by use of vasodilators such as PDE-5 inhibitors. Pulmonary Arterial Hypertension:
□ Yes □ No Patient has catheterization-proven diagnosis of Pulmonary Arterial Hypertension? AND
□ Yes □ No Patient is New York Heart Association (NYHA) or World Health Organization (WHO) Functional
Class II or III? AND
□ Yes □ No Is the patient on concurrent therapy with oral erectile dysfunction drugs? AND
□ Yes □ No Is the patient on concurrent therapy with nitrates (nitric oxide is excluded)? AND
□ Yes □ No Does the patient have Retinitis Pigmentosa?
8. 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.
IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is
privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the
employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this
information is STRICTLY PROHIBITED. If you have received this message by error, please notify us immediately at (888) 831-2242 and destroy the
related message or return the document to us at 8407 Fallbrook Avenue AF13, West Hills, CA 91304. You, the recipient, are obligated to maintain it in a
safe, secure, and confidential manner. Re-disclosure without appropriate patient consent or as permitted by law is prohibited. Unauthorized re-disclosure
or failure to maintain confidentiality could subject you to penalties described in Federal and State law.
WellPoint NextRx is a service mark of WellPoint, Inc. Services are provided by a WellPoint PBM (either Professional Claim Services Inc., doing business as WellPoint Pharmacy Management, or Anthem Prescription Management, LLC, as appropriate). WellPoint NextRx is a

Source: http://www.bcbsga.com/provider/noapplication/providerservices/downloadforms/notertiary/pw_a091167.pdf