3. Has the member received the requested drug for less than 2 years? Y N

Transcription

1 Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Zoladex (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health ew Jersey at When conditions are met, we will authorize the coverage of Zoladex (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Zoladex (goserelin) Other, specify drug Quantity Frequency Strength Route of administration Patient information Patient name: Patient ID: Patient Group o.: Patient DOB: Patient phone: Prescribing physician Expected length of therapy Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: the appropriate answer for each question. Question 1. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? [If no, skip to question 7.] 2. Is the request for treatment of a member with prostate cancer or breast cancer? [If no, skip to question 4.] 3. Has the member received the requested drug for less than 2 years? [o further questions] Reference umber: C7834-A / Effective Date: 02/01/2018 1

2 4. Is the request for treatment of a member with dysfunctional uterine bleeding? [If yes, then no further questions.] 5. Does the member have a diagnosis of gender dysphoria/gender incongruence? 6. Has the member had a response to treatment? ote: Lab results to support response to treatment (i.e., FSH, LH, weight, height, Tanner stage (if applicable), bone age (if applicable)) are required. [o further questions.] 7. Does the member have a diagnosis of advanced prostate cancer? [If no, skip to question 9.] 8. Is the requested drug being prescribed by or in consultation with an oncologist or urologist? [If yes, skip to question 12.] 9. Does the member have a diagnosis of advanced breast cancer? [If no, skip to question 13.] 10.Is this request for the 3.6mg dose of Zoladex? 11.Is the requested drug being prescribed by or in consultation with an oncologist? 12.Is the member at least 18 years old? [o further questions.] 13.Does the member have a diagnosis of endometriosis? [If no, skip to question 19.] 14.Has the member had a trial and failure of at least one formulary hormonal Reference umber: C7834-A / Effective Date: 02/01/2018 2

3 cycle control agent (e.g., Portia (ethinyl estradiol plus levonorgestrel), Ocella (ethinyl estradiol plus drospirenone), or Previfem (ethinyl estradiol plus norgestimate)), medroxyprogesterone, or Danazol? Please indicate which medication(s) the member tried: 15.Is this request for the 3.6mg dose of Zoladex? 16.Is the member at least 18 years old? 17.Is the requested drug being prescribed by or in consultation with a gynecologist or obstetrician? 18.Has the member already received 6 months of treatment with Zoladex? [o further questions.] 19.Is Zoladex requested for use as an endometrial thinning agent for dysfunctional uterine bleeding? [If no, skip to question 24.] 20.Does the member have planned endometrial ablation or hysterectomy within the next 4-8 weeks? If yes, please document date surgery is scheduled: 21.Is this request for the 3.6mg dose of Zoladex? 22.Is the member at least 18 years old? 23.Is the requested drug being prescribed by or in consultation with a gynecologist or obstetrician? [o further questions.] Reference umber: C7834-A / Effective Date: 02/01/2018 3

4 24.Is therapy being requested for treatment of a member with gender dysphoria/gender incongruence? 25.Is the diagnosis of gender dysphoria supported by the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria and an International Classification of Diseases (ICD) code? 26.Is the request for a member 18 years of age or older? [If yes, skip to question 33.] 27.Is therapy being prescribed by a pediatric endocrinologist that has collaborated care with a mental health provider (MHP)? 28.Is the request for a member who exhibits signs of puberty and has reached at least Tanner stage 2? 29.Has the member made a fully informed decision and given consent? 30.Has the member s parent/guardian given consent to treatment? 31.Are the member s comorbid conditions reasonably controlled? [ote: If there are no comorbid conditions, please answer es.] 32.Has the member been educated on any contraindications and side effects to therapy? [If yes, skip to question 36.] 33.Is therapy being prescribed by an endocrinologist that has collaborated care with a mental health provider (MHP)? Reference umber: C7834-A / Effective Date: 02/01/2018 4

5 34.Is the request for a member who has the capacity to make a fully informed decision and is consenting to treatment? 35.Are mental health concerns, if present, reasonably well controlled? [ote: If there are no mental health concerns, please answer es.] 36.Has the member been informed of fertility preservation options prior to treatment? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date Reference umber: C7834-A / Effective Date: 02/01/2018 5