Medication Prior Authorization Form

Transcription

1 Section I Member Information Name (Last, First, Middle Initial) Date of Birth WEA Trust Subscriber Number Diagnosis

2 Page 2 1. MEDICATION 2. STRENGTH 3. DIRECTIONS 4. QUANTITY FEIBA NF NovoSeven RT HEMOFIL M Koate-DVI Monoclate-P ADVATE Helixate FS Kogenate FS Novoeight RECOMBINATE Xyntha Obizur Alphanate HUMATE-P Wilate AlphaNine SD Mononine BEBULIN Profilnine SD BeneFix RIXUBIS Corifact TRETTEN RiaSTAP Specify: 5. DIAGNOSIS: 6. APPROVAL CRITERIA: CHECK ALL BOXES THAT APPLY NOTE: Any areas not filled out are considered not applicable to your patient and MAY AFFECT THE OUTCOME of this request. FEIBA NF: No Patient is using FEIBA NF to treat bleeding episodes and the patient has Hemophilia A or B No Patient is using FEIBA NF as peri-procedural operative management for surgical, invasive or interventional radiology procedures and the patient has Hemophilia A or B No Patient is using FEIBA NF as routine prophylaxis to prevent or reduce the frequency of bleeding episodes and the patient has Hemophilia A or B

3 Page 3 NovoSeven RT: No Patient is using NovoSeven RT for treatment of bleeding episodes No Patient is using NovoSeven RT for prevention of bleeding in surgical interventions or invasive procedures No Patient is using NovoSeven RT to treat Glanzmann s thrombasthenia and a documented refractoriness to platelet transfusions with or without antibodies to platelets No Does the patient have hemophilia A or B with inhibitors to Factor VIII or Factor IX; OR has the patient acquired hemophilia No Does the patient have congenital Factor VII deficiency HEMOFIL M: No Patient has hemophilia A and factor VIII deficiency and is using HEMOFIL M to treat bleeding episodes Koate-DVI OR Monoclate-P: No Patient has hemophilia A and factor VIII deficiency and is using the request drug to treat bleeding episodes No Patient has hemophilia A and factor VIII deficiency and is using the request drug as peri-procedural ADVATE OR Novoeight: No Patient has hemophilia A and factor VIII deficiency and is using the request drug to treat bleeding episodes No Patient has hemophilia A and factor VIII deficiency and is using the request drug as peri-procedural No Patient is using request drug as routine prophylaxis to prevent or reduce the frequency of bleeding Episodes If Yes: No Patient has severe hemophilia A (defined as less than or equal to 1 International Unit per deciliter [IU/dL] or 1% endogenous Factor VIII) No Patient has mild to moderate hemophilia A (defined as endogenous Factor VIII less than or equal to 40 IU/dL [less than or equal to 40%], but greater than 1 IU) If Yes: Patient has a documented history of one of the following (please indicate): No One or more episodes of spontaneous bleeding into joint No One or more episodes of spontaneous bleeding into the central nervous system No Four or more episodes of soft tissue bleeding in an eight week period Helixate FS: No Patient has hemophilia A and factor VIII deficiency and is using Helixate FS to treat bleeding episodes No Patient has hemophilia A and factor VIII deficiency and is using Helixate FS as peri-procedural No Helixate FS is being used as routine prophylaxis for a child (age 0-16 years) with hemophilia A and factor VIII deficiency to reduce the risk of joint damage in those without pre-existing joint damage

4 Page 4 No Patient is using Helixate FS as routine prophylaxis to prevent or reduce the frequency of bleeding episodes If Yes: No Patient has severe hemophilia A (defined as less than or equal to 1 International Unit per deciliter [IU/dL] or 1% endogenous Factor VIII) No Patient has mild to moderate hemophilia A (defined as endogenous Factor VIII less than or equal to 40 IU/dL [less than or equal to 40%], but greater than 1 IU) If Yes: Patient has a documented history of one of the following (please indicate): No One or more episodes of spontaneous bleeding into joint No One or more episodes of spontaneous bleeding into the central nervous system No Four or more episodes of soft tissue bleeding in an eight week period Kogenate FS: No Patient has hemophilia A and factor VIII deficiency and is using Kogenate FS to treat bleeding episodes No Patient has hemophilia A and Factor VIII deficiency and is using Kogenate FS for peri-procedural No Kogenate FS is being used for routine prophylaxis for a child (age 0-16 years) with hemophilia A and factor VIII deficiency to reduce the risk of joint damage in those without pre-existing joint damage RECOMBINATE: No Patient has hemophilia A and factor VIII deficiency and is using RECOMBINATE to treat bleeding episodes No Patient has hemophilia A and Factor VIII deficiency and is using RECOMBINATE for peri-procedural No Patient is using RECOMBINATE as treatment of acquired Factor VIII inhibitors not exceeding 10 Bethesda Unit (BU) per milliliter (ml) Xyntha: No Patient has hemophilia A and factor VIII deficiency and is using Xyntha to treat bleeding episodes No Patient has hemophilia A and Factor VIII deficiency and is using Xyntha for peri-procedural Obizur: No Patient is using Obizur for treatment of bleeding episodes in adults with acquired hemophilia A Alphanate: No Patient has a diagnosis of von Willebrand disease (Type 1,2 or unknown) If Yes No The patient has severe von Willebrand disease (VWD) No The patient has mild to moderate von Willebrand disease (VWD) and use of desmopressin is known or suspected to be inadequate If Yes: The patient is being treated for (please indicate: No Spontaneous and trauma-induced bleeding episodes No Spontaneous Peri-procedural management for surgical, invasive or interventional radiology procedures No The patient has hemophilia A and Factor VIII deficiency and is using Alphanate to treat bleeding episodes No The patient has acquired Factor VIII deficiency and is using Alphanate to treat bleeding episodes

5 Page 5 HUMATE-P: No Patient has a diagnosis of von Willebrand disease (Type 1, 2 or unknown) If Yes No The patient has severe von Willebrand disease (VWD) No The patient has mild to moderate von Willebrand disease (VWD) and use of desmopressin is known or suspected to be inadequate If Yes: The patient is being treated for (please indicate: No Spontaneous and trauma-induced bleeding episodes No Spontaneous Peri-procedural management for surgical, invasive or interventional radiology procedures No The patient has hemophilia A and Factor VIII deficiency and is using HUMATE-P to treat bleeding episodes Wilate: No Patient has a diagnosis of von Willebrand disease (Type 1, 2 or unknown) If Yes No The patient has severe von Willebrand disease (VWD) No The patient has mild to moderate von Willebrand disease (VWD) and use of desmopressin is known or suspected to be inadequate If Yes: The patient is being treated for (please indicate: No Spontaneous and trauma-induced bleeding episodes No Spontaneous Peri-procedural management for surgical, AlphaNine SD OR Mononine: invasive or interventional radiology procedures No The patient has hemophilia B and Factor IX deficiency and is using requested drug to treat bleeding episodes BEBULIN OR Profilnine SD: No The patient has hemophilia B (congenital factor IX deficiency or Christmas disease) and is using the requested drug to treat bleeding episodes BeneFix: No The patient has hemophilia B (congenital factor IX deficiency or Christmas disease) and is using the requested drug to treat bleeding episodes No The patient has hemophilia B (congenital factor IX deficiency or Christmas disease) and is using BeneFix as peri-procedural RIXUBIS: No The patient has hemophilia B (congenital factor IX deficiency or Christmas disease) and is using the requested drug to treat bleeding episodes No The patient has hemophilia B (congenital factor IX deficiency or Christmas disease) and is using BeneFix as peri-procedural No Patient has severe hemophilia B (defined as less than or equal to 1 IU/dL or 1% endogenous Factor IX) and using RIXUBIS as routine prophylaxis to prevent or reduce the frequency of bleeding episodes No Patient has mild to moderate hemophilia B (defined as endogenous Factor IX less than or equal to 40 IU/dL [less than 40% ], but greater than 1 IU/dL) and using RIXUBIS as routine prophylaxis to prevent or reduce the frequency of bleeding episodes If Yes: The patient has a documented history of one of the following (please indicate): No One or more episodes of spontaneous bleeding into joint No One or more episodes of spontaneous bleeding into the central nervous system No Four or more episodes of soft tissue bleeding in an eight week period

6 Page 6 Corifact: No Patient has Factor XIII deficiency and is using Corifact as routine prophylactic treatment No Patient has congenital Factor XIII deficiency and is using Corifact as peri-procedural management for surgical, invasive or interventional radiology procedures TRETTEN: No Patient has congenital Factor XIII A-subunit deficiency and is using TRETTEN for routine prophylaxis for bleeding RiaSTAP: No Patient has congenital fibrinogen deficiency (that is, afibrinogenemia or hypofibrinogenemia) and is using RiaSTAP to treat acute bleeding episodes

7 Page 7 Section II Physician Information Physician Name National Provider Identification (NPI) Number Clinic Name Address (Street, City, State, Zip Code) Physician Telephone Number Physician Fax Number Physician Signature Date Section III For WEA Trust Use Only Plan: Copay Tiers: Date of Receipt: Remarks: Approve Deny More information is needed Incomplete form Submission and review of this form does not guarantee approval of this request. Unless approved, payment of the brand-name medication will be limited to the amount the Trust would have paid for the generic equivalent. Insureds and providers will be informed of the decision in writing within approximately 30 days. Fax to: Pharmacy Services (608) Mail to: WEA Trust Pharmacy Services Prior Authorization P.O. Box 7338 Madison, WI