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PAxx Asacol HD/ mesalamine

U.S. Doctors Resources, L.L.C.



Asacol® HD/ mesalamine


Ulcerative Colitis, Inflammatory Bowel Disease


The Prior Authorization for this medication has been denied. Further review is pending as:
______________Alternative Pricing is Available for Delzicol® and Asacol® HD in the Exchange.
______________Sulfasalazine is available Free of Deductible in the Exchange.

1. For ulcerative colitis, IBD, Crohn's Disease, similar results are noted with 5- amainosalicyclic acids primary therapy[1] followed by DMARDs (methotrexate)[2].

2. Contact Benefit Manager for Incentivize Referral for Anabolic Protocol for adult sufferers.

Pending (1.) and (2.) the employee/ dependent may continue the medication as prescribed by the treating physician by attaching a valid 3-month prescription with up to 12-months of refills to the Cover Page and mailing it back to:

ATTN: Benefit Manager
Self-Insurance Health Program

Please send the demographics about the patient that appear on the Cover Page of the Prior Authorization form and the Credit Card Information from the Flexible Spending Account, if applicable, in the boxes below.


Demographics Health Insurance/ Credit Card
Member Name:____________________________________ Member Name on the Card:_____________________________________
Insurance ID:____________________________________ Issuing Service: VISA, MC, Discover _________________
Date of Birth:____________________________________ Number:____________________________________
Street Address:____________________________________ Expiration:____________________________________
City/ State/ Zip code:____________________________________CVV Code:____________________________________
Telephone Number:____________________________________
Signature of Employee/ Insured:

Signature of Treating Physician:___________________________________

1. J Gastroenterol. 2011 Apr;106(4):601-16. doi: 10.1038/ajg.2011.67. Epub 2011 Mar 15. Efficacy of 5-aminosalicylates in ulcerative colitis: systematic review and meta-analysis. Ford AC, Achkar JP, Khan KJ, Kane SV, Talley NJ, Marshall JK, Moayyedi P.

2. Cochrane Database Syst Rev. 2015 Aug 11;8:CD007560. doi: 10.1002/14651858.CD007560.pub3. Methotrexate for maintenance of remission in ulcerative colitis. Wang Y, MacDonald JK, Vandermeer B, Griffiths AM, El-Matary W.

Signed b.n.r. Benefit Manager ___________________________________ date:__________

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