®
CONFIDENTIAL
PATIENT INFORMATION
®
DRUG AUTHORIZATION FORM
Hereditary Angioedema and
Fentanyl Agents
An independent licensee of the Blue Cross and Blue Shield Association.
P.O. Box 98031 ● Baton Rouge, Louisiana ● 70898-9031
PATIENT DATA
Last Name
Phone: 800-842-2015 Fax: 877-837-5922
First Name
Policy Number
REQUESTING
Last Name
PHYSICIAN DATA
BCBSLA Provider Number
Area of Practice/Specialty
BILLING DATA
Diagnosis Code(s) (ICD-9):
1)
2)
First Name
Contact Name
Name of Place of Treatment Treatment Center
Provider #
CPT-4/HCPCS Code
Date of Birth
Age
Fax Number
(
)
Phone Number
(
)
Other Codes
DRUG INFORMATION
Fentanyl agents:
ABSTRAL®
ACTIQ®
Hereditary Angioedema agents:
FENTORA®
LAZANDA®
ONSOLIS®
SUBSYS®
BERINERT®
OTHER:_______________
Dosage and Frequency:
Anticipated Start
Date:
CINRYZE®
FIRAZYR®
KALBITOR®
INDICATION / DIAGNOSIS
For FENTANYL Agents:
Breakthrough cancer pain in patient with malignancies already receiving opioid therapy
Patient is opioid tolerant
For Hereditary Angioedema (HAE) Agents:
Hereditary angioedema
History of laryngeal edema or airway compromise with an episode of HAE or a history of at least 2 HAE attacks per month
Other Indication: ___________________________________________________________________________________________
CLINICAL INFORMATION (Check ALL that apply)
For Hereditary Angioedema (HAE) Agents:
Yes
No Has the HAE diagnosis been confirmed by the appropriate, documented lab tests?
Yes
No Are the attacks acute?
Yes
No Is this for the prevention of angioedema attacks?
Yes
No Will the patient be receiving the drug in the physician’s office? If no, list name of servicing provider:
_____________________________________________________________________________________________________________
List any relevant clinical info if applicable:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
PHYSICIAN SIGNATURE
DATE
__________________________________________________
_______________________________________
Prescribing Physician
Note: On behalf of Blue Cross and Blue Shield of Louisiana, prior authorizations are administered by Express Scripts, Inc., an
independent pharmacy benefit management company. Please note that the authorization is not a guarantee of payment. Payment is
subject to the member’s eligibility, benefits, and pre-existing condition limitations at the time the services are provided. We recommend
you contact BCBSLA at 800-922-8866 to verify benefits. The submitting provider certifies that the information contained herein is
true, accurate, and complete and the requested services are medically necessary to the health of the patient.
Incomplete forms will not be processed
04HQ1081 R06/12
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company