PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR BELSOMRA® 2 of 2 F-01673 (01/2016) SECTION III CLINICIAL INFORMATION (Continued) — 17. Has the member experienced an unsatisfactory therapeutic response or a clinically significant adverse drug reaction with at least two preferred drugs from the Sedative Hypnotics drug class? Yes No If yes, list the drug name and dates the drug was taken in the space provided for at least two preferred drugs the member has taken from the Sedative Hypnotics drug class. Drug Name Dates Taken Drug Name Dates Taken Drug Name Dates Taken Describe the unsatisfactory therapeutic response(s) or clinically significant adverse drug reaction(s). SECTION IV AUTHORIZED SIGNATURE — 18. SIGNATURE Prescribing Provider 19. Date Signed — SECTION V FOR PHARMACY PROVIDERS USING STAT-PA — 20. National Drug Code (11 Digits) to 365 Days) 21. Days’ Supply Requested (Up 22. NPI 23. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up to 14 days in the past.) 24. Place of Service 25. Assigned PA Number 26. Grant Date 27. Expiration Date 28. Number of Days Approved SECTION VI ADDITIONAL INFORMATION — 29. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the drug requested may be included here.
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR BELSOMRA® 2 of 2 F-01673 (01/2016) SECTION III — CLINICIAL INFORMATION (Continued) 17. Has the member experienced an unsatisfactory therapeutic response or a clinically significant adverse drug reaction with at least two preferred drugs from the Sedative Hypnotics drug class? Yes No If yes, list the drug name and dates the drug was taken in the space provided for at least two preferred drugs the member has taken from the Sedative Hypnotics drug class. Drug Name Dates Taken Drug Name Dates Taken Drug Name Dates Taken Describe the unsatisfactory therapeutic response(s) or clinically significant adverse drug reaction(s). SECTION IV — AUTHORIZED SIGNATURE 18. SIGNATURE — Prescribing Provider 19. Date Signed SECTION V — FOR PHARMACY PROVIDERS USING STAT-PA 20. National Drug Code (11 Digits) 21. Days’ Supply Requested (Up to 365 Days) 22. NPI 23. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up to 14 days in the past.) 24. Place of Service 25. Assigned PA Number 26. Grant Date 27. Expiration Date 28. Number of Days Approved SECTION VI — ADDITIONAL INFORMATION 29. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the drug requested may be included here.
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