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Topical Post Limit PA

PHYSICIAN PRIOR AUTHORIZATION REQUEST FORM

Patient Information

Name: Member ID #: Group Name: Date of Birth: Diagnosis: Diagnosis Code:

Provider Information

Prescriber’s Name: Prescriber’s DEA #: Phone Number: Fax Number: Office Address:

Complete and review information, sign and date. Fax signed form to Caremark’s Prior Authorization department at 888-836-0730. Caremark is an independent company that provides pharmacy benefit management services, including prior authorization review, on behalf of the member’s health plan. The Caremark fax machine is located in a secure location as required by HIPAA regulations.

Providers can call Caremark at 800-294-5979 with any questions concerning prior authorization procedures. Members should call Caremark Customer Care at 888-963-7290 with any questions. Members can also call their health plan at the number on their member ID cards.

1. Is the requested drug being prescribed for a -responsive dermatosis or condition Yes No (e.g., eczema, atopic dermatitis, seborrheic dermatitis, psoriasis)?

2. Which drug is being requested (applies to brand or generic)? [Note: Please check which drug (applies to brand or generic).]

[] Aclovate () (if checked, go to 3) [] Ala-Scalp () (if checked, go to 4) [] Alclometasone (if checked, go to 3) [] (if checked, go to 5) [] Apexicon E ( diacetate) (if checked, go to 6) [] Dipropionate (if checked, go to 7) [] (if checked, go to 7) [] Bryhali (halobetasol) (if checked, go to 16) [] Clobex () (if checked, go to 8) [] Cloderm () (if checked, go to 17) [] Cordran (flurandrenolide) (if checked, go to 9) [] Cutivate () (if checked, go to 10) [] Dermatop (prednicarbate) (if checked, go to 17) [] Desonate () (if checked, go to 11) [] Desonide (if checked, go to 11) [] DesOwen (desonide) (if checked, go to 11) [] Diflorasone (if checked, go to 6) [] Diprolene, Diprolene AF (betamethasone dipropionate augmented) (if checked, go to 7) [] Elocon () (if checked, go to 12) [] (if checked, go to 13) [] (if checked, go to 14) [] Fluticasone (if checked, go to 10) [] Halog () (if checked, go to 17) [] Hydrocortisone, (if checked, go to 4)

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[] Impoyz (clobetasol) (if checked, go to 8) [] Locoid, Locoid Lipocream () (if checked, go to 4) [] LoKara (desonide) (if checked, go to 11) [] MiCort HC () (if checked, go to 4) [] Nolix (flurandrenolide) (if checked, go to 9) [] Pandel (hydrocortisone probutate) (if checked, go to 4) [] Psorcon (diflorasone) (if checked, go to 6) [] Synalar (fluocinolone) (if checked, go to 13) [] Temovate, Temovate E (clobetasol) (if checked, go to 8) [] Topicort () (if checked, go to 17) [] (if checked, go to 15) [] Trianex (triamcinolone) (if checked, go to 15) [] Tridesilon (desonide) (if checked, go to 11) [] Ultravate (halobetasol) (if checked, go to 16) [] Vanos (fluocinonide) (if checked, go to 14) [] Westcort (hydrocortisone valerate) (if checked, go to 4)

3. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 240 grams of Aclovate (alclometasone) cream, B) 240 grams of alclometasone ointment? [No further questions.]

4. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 240 milliliters of Ala-Scalp (hydrocortisone) lotion, B) 180 grams of Locoid (hydrocortisone butyrate) cream or ointment, C) 180 grams of Locoid Lipocream (hydrocortisone butyrate), D) 180 milliliters of Locoid (hydrocortisone butyrate) lotion, E) 240 grams of MiCort HC (hydrocortisone acetate) cream, F) 160 grams of Pandel (hydrocortisone probutate), G) 180 grams of Westcort (hydrocortisone valerate) ointment, H) 240 grams of hydrocortisone cream or ointment, I) 240 milliliters of hydrocortisone lotion, J) 180 grams of hydrocortisone valerate cream? [No further questions.]

5. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 180 grams of amcinonide cream or ointment, B) 180 milliliters of amcinonide lotion? [No further questions.]

6. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 180 grams of Apexicon E () emollient cream, B) 180 grams of Psorcon (diflorasone) cream, C) 180 grams of diflorasone ointment? [No further questions.]

7. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 150 grams of Diprolene (betamethasone dipropionate augmented) ointment, B) 150 grams of Diprolene AF (betamethasone dipropionate augmented) cream, C) 180 milliliters of Diprolene (betamethasone dipropionate augmented) lotion, D) 150 grams of betamethasone dipropionate augmented gel, D) 150 grams of betamethasone dipropionate unaugmented cream or ointment, E) 180 milliliters of betamethasone dipropionate unaugmented lotion, F) 150 grams of betamethasone valerate cream or ointment, F) 180 milliliters of betamethasone valerate lotion? [No further questions.]

8. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 180 milliliters of Clobex (clobetasol) lotion, B) 180 grams of Impoyz (clobetasol), C) 180 grams of Temovate (clobetasol), D) 180 grams of Temovate E (clobetasol emollient)? [No further questions.]

9. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 240 grams of Cordran (flurandrenolide) cream, B) 240 milliliters of Cordran (flurandrenolide) lotion, C) 180 grams of Cordran (flurandrenolide) ointment, D) 240 grams of Nolix (flurandrenolide) cream, E) 240 milliliters of Nolix (flurandrenolide) lotion? [No further questions.]

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10. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 150 grams of Cutivate (fluticasone) cream, B) 240 milliliters of Cutivate (fluticasone) lotion, C) 150 grams of fluticasone ointment? [No further questions.]

11. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 240 grams of Desonate (desonide) gel, B) 240 grams of DesOwen (desonide) cream, C) 240 milliliters of DesOwen (desonide) lotion, D) 240 milliliters of LoKara (desonide), E) 240 grams of Tridesilon (desonide), F) 240 grams of desonide ointment? [No further questions.]

12. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 150 grams of Elocon (mometasone) cream, B) 150 grams of Elocon (mometasone) ointment, C) 180 milliliters of Elocon (mometasone) lotion? [No further questions.]

13. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 240 grams of Synalar (fluocinolone) 0.025 percent cream or ointment, B) 240 grams of fluocinolone 0.01 percent cream? [No further questions.]

14. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 150 grams of Vanos (fluocinonide 0.1 percent), B) 150 grams of fluocinonide 0.05 percent cream, emulsified base cream, gel or ointment? [No further questions.]

15. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 430 grams of Trianex (triamcinolone), B) 160 grams of triamcinolone 0.025 percent cream or ointment, C) 160 grams of triamcinolone 0.1 percent cream or ointment, D) 150 grams of triamcinolone 0.5 percent cream or ointment, E) 180 milliliters of triamcinolone lotion? [No further questions.]

16. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 180 grams of Bryhali (halobetasol) lotion, B) 150 grams of Ultravate (halobetasol) cream, C) 180 milliliters of Ultravate (halobetasol) lotion, D) 150 grams of Ultravate (halobetasol) ointment? [No further questions.]

17. Does the patient require more than the plan allowance PER MONTH of one of the following: A) Yes No 150 grams of Cloderm (clocortolone) cream, B) 180 grams of Dermatop (prednicarbate) cream or ointment, C) 150 grams of Halog (halcinonide) cream or ointment, D) 180 grams of Topicort cream, gel, or ointment?

Comments: ______

Information on this form is accurate as of this date. Prescriber’s Signature: Date:

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