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CONTAINS CONFIDENTIAL PATIENT INFORMATION
Diovan (valsartan) and
Diovan HCT (valsartan hydrochlorothiazide)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (866) 807- 6241
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 #: _____________________________ hysician Email Address: ___________________________ 3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
□ Diovan HCT (valsartan □ 80mg/12.5 □ 160mg/12.5 ____________________ 7. DIAGNOSIS: ___________________________________________________________________________________
8. 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.
Diovan (valsartan)
□ Yes □ No Patient has had a failure or intolerance to any Angiotensin Converting Enzyme inhibitor □ Yes □ No Patient has tried and failed Cozaar □ Yes □ No Patient is currently maintained on Diovan in the previous 90 days
Diovan HCT (valsartan hydrochlorothiazide)
□ Yes □ No Patient has had a failure or intolerance to any Angiotensin Converting Enzyme inhibitor □ Yes □ No Patient has tried and failed Hyzaar □ Yes □ No Patient is currently maintained on Diovan HCT in the previous 90 days 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 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 BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. Healthy Connections is administered for BlueChoice HealthPlan by WellPoint Partnership Plan, LLC, an independent company.

Source: http://www.bluechoicescmedicaid.com/UserFiles/bluechoice/Documents/Providers/SC_SSB_Diovan_PAB_Fax_Form.pdf