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Contents : ACTOS AVANDIA JANUVIA and ONGLYZA Prior Authorization Form IF THIS IS AN URGENT REQUEST Please Call UPMC Health Plan Pharmacy Services. Otherwise please return completed form to: UPMC HEALTH PLAN PHARMACY SERVICES Office Contact: PHONE 800-979-UPMC (8762) FAX 412-454-7722 PLEASE TYPE OR PRINT NEATLY. Incomplete responses may delay this request. Provider Specialty: Provider First Name: Provider Last Name: Provider Phone: Provider Fax: Patient Name: Patient UPMC Health Plan ID Number: Drug Requested: Brand Generic Strength: Frequency: Patient Age: Patient DOB: Expected length of therapy: Generic equivalent drugs will be substituted for Brand name drugs unless you specifically indicate otherwise. New medication Ongoing medication Diagnosis: If ongoing provide date started: If medication is ongoing Did member Show improvement while on therapy Medical History Has the member previously failed or had intolerance to Metformin Yes No Yes No If Yes Please complete below: Medication Name Strength/Frequency Dates of Therapy Reason for Discontinuation Please list all diabetic medications the member has previously tried or is currently using. Medication Name Strength Frequency Dates of Trial Start Date End Date List adverse reactions/side effects/reason for discontinuation Please provide any additional information which should be considered in the space below: Oral diabetes PA form All PA forms available at www.upmchealthplan.com/providers/pa forms.html February 2011

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