Date of request:

PRIOR AUTHORIZATION REQUEST
Leukotriene Inhibitors
Please Fax Form to: 419-887-2028
Physician/Providers Inquiry only: 419-887-2520, Option 2 then Option 1

MEMBER NAME: ____________________________________________ Date of Request: ________________
Paramount Member ID Number: _________________________________ DOB: __________________________
PRESCRIBER NAME: ______________________________SIGNATURE: ______________________________
Provider Address: ________________________________________ Paramount Provider ID:_______________
Phone: _____________________ Fax: _______________________ Contact Name: _____________________

Paramount Member is enrolled in: □Elite™/ Medicare Part D

STEP THERAPY
STEP 1*
STEP 2
Elite®
Enhanced Part D
Singulair®, Zafirlukast, Accolate®(brand) Elite®
Standard Part D
 *Over-the-Counter (OTC) products are covered with a prescription written by a licensed prescriber.
Cetirizine OTC (formerly branded Zyrtec®) and loratadine OTC (formerly branded Claritin®) are covered
under the pharmacy benefit at a zero-dollar ($0) copay if written as a prescription and filled through the
pharmacy.
Prior Authorization Request for a Leukotriene Inhibitor for which step therapy has not been met:
» Drug/Dosage/Frequency Requested: __________________________________ «
» Diagnosis: __________________________________ « Drug, Dose, Frequency Dates Intolerance, Lack of Efficacy or Adverse Reaction Sample?
_______________________ ___________ _________________________________________
_______________________ ___________ _________________________________________
Yes No
If step therapy has been met but is not reflected in the member’s current pharmacy profile, please provide information drug, dose, frequency and dates of utilization. This form is available at: www.paramounthealthcare.com >> Prescription Drug Program >> Prior Authorization Forms

CONFIDENTIALITY NOTICE The documents accompanying this fax 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 required to do so by law or regulation and is required to destroy the information after its stated need has been fulfilled. 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 these documents. Last Update: July 2011

Source: http://paramounthealthcare.com/documents/Paramount%20Elite/2011%20Medicare/Leukotriene%20Inhibitors%20Request%20Form-Part%20D%202011-07.pdf