Pharmacy Prior Authorization

Transcription

1 Pharmacy Prior Authorization MERC CARE (MEDICAID) Promacta (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 Mercy Care at When conditions are met, we will authorize the coverage of Promacta (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Promacta (eltrombopag) Other, specify drug Quantity Frequency Strength Route of administration Expected length of therapy Patient information Patient name: Patient ID: Patient Group o.: Patient DOB: Patient phone: Prescribing physician Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: Circle the appropriate answer for each question. Question Circle es or o Requests for Promacta will only be accepted by fax and with the appropriate medical records and lab results. Requests will not be taken over the phone. 1. Is this a request for a patient who is CURRETL taking Promacta? [If no, skip to question 16.] 2. Does the patient have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)? Reference umber: C6582-A/ Effective Date: 09/01/2016 1

2 [If no, skip to question 6.] Circle es or o 3. Does the patient have a platelet count of at least 50,000/mm3? OTE: Lab results for platelets must be submitted with 4. Has the patient received 8 weeks of treatment with Promacta? 5. Is the dose of Promacta being increased? OTE: Dose should be increased by 25mg to a maximum of 75mg [o further questions.] 6. Does the patient have a diagnosis of aplastic anemia? [If no, skip to question 11.] 7. Does the patient have a platelet count of at least 50,000/mm3? OTE: Lab results for platelets must be submitted with 8. Has the patient received 16 weeks of treatment with Promacta? [If no, skip to question 10.] 9. Has the patient had a response to treatment indicated by at least OE of the following: A) Platelet count increase by at least 20,000/mm3 above baseline; B) Stable platelet count without requiring transfusions for at least 8 weeks; C) Hemoglobin increase by more than 1.5 g/dl above baseline; D) Reduction in RBC transfusions by at least 4 units for 8 consecutive weeks; E) Doubling of baseline AC or an increase in AC to above 500? OTE: Lab results to support a response to Promacta must be submitted with request. Requests without lab results will Reference umber: C6582-A/ Effective Date: 09/01/2016 2

3 not be accepted. Circle es or o [o further questions.] 10.Is the dose of Promacta being increased? OTE: The dose should be increased by 50mg every 2 weeks until platelets are at least 50,000/mm3 or to a maximum of 150mg. [o further questions.] 11.Does the patient have a diagnosis of Hepatitis C with thrombocytopenia? 12.Does the patient have a platelet count of at least 90,000/mm3? OTE: Lab results for platelets must be submitted with [If no, skip to question 14.] 13.Has a separate prior authorization been submitted to start antiviral treatment with pegylated interferon? [o further questions.] 14.Has the patient received 8 weeks of treatment with Promacta OR has the dose been increased to the maximum of 100mg? 15.Is the dose of Promacta being increased? OTE: The dose should be increased by 25mg every 2 weeks until platelets are at least 90,000 or to a maximum of 100mg. [o further questions.] 16.Does the patient have a diagnosis of idiopathic thrombocytopenic purpura (ITP)? [If no, skip to question 20.] 17.Has the patient had an insufficient response to corticosteroids, immunoglobulins, or splenectomy? Reference umber: C6582-A/ Effective Date: 09/01/2016 3

4 Circle es or o If yes, please document prior therapies or submit records: 18.Is Promacta being used to prevent major bleeding in a patient with a platelet count of less than 30,000/mm3? OTE: Promacta is not approved to achieve platelet counts in the normal range (i.e., 150, ,000/mm3) OTE: Lab results for platelets must be submitted with 19.Is the patient at least 1 year of age? [o further questions.] 20.Is Promacta requested to treat thrombocytopenia due to chronic hepatitis C infection in a patient with a platelet count of less than 90,000/mm3? OTE: Lab results for platelets must be submitted with [If no, skip to question 22.] 21.Does the patient require treatment for hepatitis C with a regimen that contains pegylated interferon? If yes, please document patient characteristics and rationale for requiring Peg-IF: [If yes, skip to question 25.] 22.Does the patient have a diagnosis of severe aplastic anemia confirmed by bone marrow biopsy showing less than 25% of normal cellularity? OTE: Medical records to support diagnosis must be submitted with request. Requests without records will not be accepted. [If yes, skip to question 24.] Reference umber: C6582-A/ Effective Date: 09/01/2016 4

5 Circle es or o 23.Does the patient have a diagnosis of severe aplastic anemia confirmed by bone marrow biopsy showing less than 50% of normal cellularity AD at least TWO of the following: A) Absolute neutrophil count (AC) less than 500/mm3; B) Platelet count less than 20,000/mm3; C) Absolute reticulocyte count less than 40,000/mm3? OTE: Medical records and lab results to support diagnosis must be submitted with request. Requests without records will not be accepted. 24.Is the anemia refractory to first line treatment with either hematopoietic cell transplantation OR immunosuppressive therapy with a combination of cyclosporine A and antithymocyte globulin (ATG)? OTE: Documentation of previous treatment must be included with request. 25.Is the patient at least 18 years old? 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: C6582-A/ Effective Date: 09/01/2016 5