Drug Name (select from list of drugs shown / provide drug information) Patient Information. Prescribing Physician

Transcription

1 Texas Standard Prior Authorization Form Addendum MOLINA TX MARKETPLACE Botulinum Toxins CL Molina Universal This fax machine is located in a secure location as required by HIPAA Regulations. Complete / Review information, sign, and date. Fax signed forms to Molina Pharmacy Prior Authorization Department at Please contact Molina Pharmacy Prior Authorization Department at with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Botulinum Toxins CL. Drug Name (select from list of drugs shown / provide drug information) Botox Xeomin Dysport Myobloc Patient Name: Patient ID: Patient DOB: Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: Directions for administration: Patient Information Prescribing Physician ICD Code: Please circle the appropriate answer for each question. 1. Is the requested medication being prescribed for cosmetic treatment of hyperfunctional wrinkles Y N of the upper face including glabellar frown lines, deep forehead wrinkles and periorbital wrinkles (crow's feet)? If the answer to this question is no, go to question Is the request for Myobloc? Y N If the answer to this question is yes, go to question 3. If the answer to this question is no, go to question Is the medication being prescribed to treat cervical dystonia? Y N If the answer to this question is yes, go to question 4.

2 4. Does the prescribed dose meet the following criteria? Y N - The prescribed dose does not and will not exceed 10,000 units total per treatment, divided among affected muscles - The medication will not be given more frequently than every 12 weeks If the answer to this question is yes, approved for 6 months, 10,000 units per 12 weeks 5. Is the requested medication being prescribed to treat chronic migraine headache? Y N If the answer to this question is yes, go to question 6. If the answer to this question is no, go to question Does the patient meet all of the following criteria? Y N - The patient has a persistent history of chronic, debilitating migraine headaches with frequent attacks on 15 or more days per month for longer than 3 months - A neurologist has thoroughly evaluated the patient and has established a diagnosis of chronic migraine headaches - There is documentation of significant functional disability (e.g., work absenteeism, multiple emergency department visits) If the answer to this question is yes, go to question 8 7. Does the patient meet both of the following criteria? Y N - The patient has failed or had a clinically significant adverse reaction to abortive treatment with different therapy classes, including at least three (3) of the following classes: Triptans [Imitrex (sumatriptan), Maxalt (rizatriptan), Zomig (zolmitriptan), Amerge (naratriptan), Axert (almotriptan), Frova (frovatriptan), Relpax (eletriptan)], ergot derivatives [Cafergot (ergotamine/caffeine), D.H.E.-45 (dihydroergotamine)], analgesics [Aspirin, acetaminophen, opioids (morphine, oxycodone)], opioid combinations [APAP/codeine, APAP hydrocodone], non-steroidal anti-inflammatory agents (NSAIDs) [Motrin (ibuprofen), Naprosyn (naproxen), Relafen (nabumetone), Voltaren (diclofenac), Orudis (ketoprofen), Clinoril (sulindac), Toradol (ketorolac)], and combination products [Midrin (isometheptene/apap), Fiorinal (butalbital/aspirin), Fioricet (butalbital/apap)] - The patient has failed or had a clinically significant adverse reaction to different prophylactic therapies, including at least three (3) of the following classes: Anticonvulsants [Depakote (divalproex), Topamax (topiramate)], beta blockers [Inderal (propranolol), Lopressor (metoprolol), Tenormin (atenolol)], calcium channel blockers [Procardia (nifedipine), Cardizem (diltiazem), Calan (verapamil)], antidepressants/ tricyclic antidepressants [Elavil (amitriptyline), Tofranil (imipramine), Pamelor (nortriptyline), venlafaxine (Effexor )]. 8. Is the requested medication being prescribed for one of the following diagnoses? Y N - Strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorders in patients 12 years of age or older - Hemifacial spasm - Facial spasm - Jaw-closing oromandibular dystonia - Spasmodic dysphonia (laryngeal dystonia, lingual dystonia, laryngeal spasm) - Spasmodic Torticollis (cervical dystonia) - Focal task-specific dystonia - Head and neck tremor - Dynamic muscle contractions in pediatric cerebral palsy - Limb spasticity, including: Heredity spastic paraplegia; Limb spasticity due to multiple sclerosis

3 or other demyelinating diseases of the central nervous system; Spastic hemiplegia; Infantile cerebral palsy - Frey's Syndrome (gustatory sweating) secondary to parotid surgery - Sialorrhea in Parkinson's Disease - Detrusor sphincter dyssynergia (lower urinary tract dysfunction) If the answer to this question is no, go to question Is the requested medication being prescribed to treat overactive bladder or urinary incontinence Y N due to detrusor overactivity associated with a neurologic condition? If the answer to this question is yes, go to question 10. If the answer to this question is no, go to question Has the patient has had an inadequate response to or clinically significant adverse reaction to at least two anticholinergic agents (oxybutynin immediate and extended release tabs, Oxytrol patch, Gelnique gel, tolterodine immediate and extended release, Toviaz, Enablex, Vesicare, trospium immediate and extended release)? 11. Is the requested medication being prescribed to treat focal hand dystonia (organic writer's cramp)? Y N If the answer to this question is yes, go to question 13. If the answer to this question is no, go to question Are all of the following criteria met? Y N - The condition is incapacitating and refractive to medical treatment including oral medications. - Documentation of functional limitations has been provided - The Patient has failed or had a clinical significant adverse reaction to oral medication (baclofen, beta-blockers and benzodiazepines) 13. Is the requested medication being prescribed to treat primary (idiopathic) esophageal achalasia? Y N If the answer to this question is yes, go to question 14. If the answer to this question is no, go to question Does the patient meet any of the following criteria? Y N - The patient has failed or had a clinically significant adverse reaction to conventional therapy (nitrates or calcium channel blockers) OR - The patient is ineligible for surgical treatment due to advance age or multiple co-morbidities (poor surgical risk) OR - The patient is at high risk of complications of pneumatic dilation or surgical myotomy OR - Failure of prior myotomy or dilation OR - The patient has an epiphrenic diverticulum or hiatal hernia, both of which increase the risk of dilation-induced perforation 15. Is the requested medication being prescribed to treat focal, primary axillary or palmar hyperhidrosis Y N If the answer to this question is yes, go to question 17. If the answer to this question is no, go to question Does the patient meet both of the following criteria? Y N

4 - The patient has failed or had a clinically significant adverse reaction to topical antiperspirants (e.g., Drysol ) - Condition creates a significant disruption to patient s daily life and ability to work/function or patient has recurrent or chronic irritations and/or infections, dermatitis, skin macerations 17. Is the requested medication being prescribed to treat chronic anal fissure? Y N If the answer to this question is yes, go to question 18. If the answer to this question is no, go to question Has the patient failed or had a clinically significant adverse reaction to topical nitroglycerin or a topical Y N calcium channel blocker? 19. Is the requested medication being prescribed to treat a member with internal anal sphincter (IAS) achalasia? Y N If the answer to this question is yes, go to question Does the patient meet both of the following criteria? Y N - The patient has not responded to treatment with laxatives - The patient has not responded to or is not a candidate for anal sphincter myectomy 21. Is the requested medication Botox? Y N If the answer to this question is yes, go to question 22. If the answer to this question is no, go to question Is the medication being prescribed for one of the following indications? Y N - Blepharospasm - Strabismus - Cervical dystonia - Overactive bladder - Axillary hyperhidrosis - Migraines - Neurogenic bladder - Upper Limb Spasticity - Lower Limb Spasticity If the answer to this question is yes, go to question 23. If the answer to this question is no, go to question Does/Will the prescribed dose exceed the following? Y N - Blepharospasm: 5 units per site - Strabismus: 5 units per muscle (maximum 25 units total) - Cervical dystonia: 300 units total, divided among affected muscles - Overactive bladder: 100 units total, at least 12 weeks apart between treatments - Axillary hyperhidrosis: 50 units per axilla - Migraines: 155 total units (5 to 40 units per site) - Neurogenic bladder: 200 units total, given in multiple sites - Upper Limb Spasticity: 50 units in one site

5 - Lower Limb Spasticity: 400 units divided across 5 muscles If the answer to this question is no, approved for 6 months. 24. Is the medication being prescribed for one of the following indications? Y N - Oromandibular dystonia - Spasmodic dysphonia - Spastic muscle contracture of pediatric cerebral palsy - Childhood myoclonus following failure of Baclofen, benzodiazepines, and anti-seizure medications - Chronic anal fissure - Gustatory sweating (Frey's syndrome) - Internal anal sphincter (IAS) achalasia - Plantar/palmar hyperhidrosis If the answer to this question is yes, go to question 25. If the answer to this question is no, go to question Will the prescribed dose exceed the following? Y N - Oromandibular dystonia: 50 units per masseter muscle and 40 units per temporalis - Spasmodic dysphonia: 10 units per vocal cord and 30 units in abductor muscle - Spastic muscle contracture of pediatric cerebral palsy: 12 units/kg and 220 units divided among affected muscles - Childhood myoclonus following failure of Baclofen, benzodiazepines, and antiseizure medications: 80 units/kg - Chronic anal fissure: 20 units both sides - Gustatory sweating (Frey's syndrome): 75 units per injection - Internal anal sphincter (IAS) achalasia: 25 units in each quadrant or 50 units on either side of IAS - Plantar/palmar hyperhidrosis: 165 units per palm If the answer to this question is no, approved for 6 months. 26. Is the request for Dysport? Y N If the answer to this question is yes, go to question 27. If the answer to this question is no, go to question Is the medication being prescribed for cervical dystonia? Y N If the answer to this question is yes, go to question 28. If the answer to this question is no, go to question Does the prescribed dose meet the following criteria? Y N - The prescribed dose does not and will not exceed 500 units total per treatment, divided among affected muscles - The medication will not be given more frequently than every 12 weeks If the answer to this question is yes, approved for 6 months, 500 units per 12 weeks 29. Is the request for Xeomin? Y N If the answer to this question is yes, go to question Is the medication being prescribed for cervical dystonia or blepharospasm? Y N If the answer to this question is yes, go to question 31. If the answer to this question is no, go to question Does/Will the prescribed dose exceed the following? Y N

6 - Cervical dystonia: a total dose of 300 units per treatment - Blepharospasm: 35 units per eye If the answer to this question is no, approved for 6 months. 32. Is the medication being prescribed at clinically appropriate doses? Y N If the answer to this question is yes, approved for 6 months. Comment I affirm that the information given on this form is true and accurate as of this date. Prescriber (or Authorized) Signature Date