01/03/2012 <%PANumber%>
BCBS TENNESSEE (N386)
Nasal Steroids Step Therapy

This fax machine is located in a secure location as required by HIPAA regulations.
Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-888-836-0730.
Please contact CVS/Caremark at 1-877-916-2271 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of Nasal Steroids Step Therapy.


Drug Name (select from list of drugs shown)
Beconase AQ Flonase Nasacort AQ
Nasonex Omnaris Rhinocort Aqua

Patient Information
Patient Name:    
Patient ID:    
Patient Group No.:    
Patient DOB:    

Prescribing Physician
Physician Name:    
Physician Phone:    
Physician Fax:    
Physician Address:    
City, State, Zip:    

Diagnosis:     ICD Code:  
Please circle the appropriate answer for each question.
  1. Does the participant have a documented contraindication to or a potential drug interaction with generic nasal steroid (e.g., flunisolide nasal, fluticasone nasal, triamcinolone nasal) or Veramyst?
    Y   N    
   [If the answer to this question is yes, then no further questions required.]
  2. Is the patient intolerant to or had a confirmed adverse event with generic nasal steroid (e.g., flunisolide nasal, fluticasone nasal, triamcinolone nasal) or Veramyst?
    Y   N    
   [If the answer to this question is yes, then no further questions required.]
  3. Has the participant demonstrated an inadequate treatment response after at least a 30 day trial of a generic nasal steroid (e.g., flunisolide nasal, fluticasone nasal, triamcinolone nasal) or Veramyst?
    Y   N    

Comments:  

I affirm that the information given on this form is true and accurate as of this date.

 
Prescriber (Or Authorized) Signature and Date