2. Is the request for Alli, Xenical or Belviq? Y N. 3. Has the patient received 6 months or more of therapy? Y N

Transcription

1 Prior Authorization MERC CARE PLA Weight Reduction Medications (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 Plan at When conditions are met, we will authorize the coverage of Weight Reduction Medications (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (please circle) Please specify Quantity Frequency Strength Route of Administration Patient Information Patient ame: Patient ID: Patient Group o.: Patient DOB: Patient Phone: Prescribing Physician Expected Length of therapy Physician ame: Specialty: PI umber: Physician Fax: Physician Phone: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. 1. Has this plan authorized this medicine in the past for this patient (e.g. previous authorization is on file under this plan)? [If no, then skip to question 7.] 2. Is the request for Alli, Xenical or Belviq? 3. Has the patient received 6 months or more of therapy? [If no, then skip to question 6.] 4. Has the patient continued with their weight loss plan and maintained 67 percent of their initial weight loss to date? Reference umber: C6832-A / Effective Date: 03/06/2017 1

2 If yes, please provide current weight: 5. Is the patient s BMI greater than or equal to 24 kg per square meter? Please provide current BMI: [o further questions.] 6. Has the patient had a documented weight loss of at least 4 pounds per month? If yes, please.provide current weight: [o further questions.] 7. Is the request for Belviq? [If no, then skip to question 10.] 8. Is the patient taking any of the following: A) SSRIs, SRIs, MAOIs; B) linezolid; C) triptans; D) tramadol; E) bupropion; F) dextromethorphan; G) St. John s wort? 9. Does the patient have severe renal impairment? [If no, then go to question 22.] 10. Is the request for Contrave? [If no, then skip to question 13.] 11. Has the patient been abstinent from opioids for a minimum of 7 to 10 days (up to 14 days if taking long-acting opioid) prior to starting naltrexone/bupropion? Reference umber: C6832-A / Effective Date: 03/06/2017 2

3 12. Does the patient have any of the following: A) uncontrolled hypertension; B) use of MAOI within 14 days; C) Seizure disorder? [If no, then skip to question 22.] 13. Is the request for Qsymia? [If no, then skip to question 15.] 14. Does the patient have any of the following: A) Hyperthyroidism; B) Glaucoma; C) Agitation or uncontrolled anxiety; D) MAOI use within 14 days; E) History of drug abuse; F) Concomitant use with CS stimulants; G) Uncontrolled hypertension; H) History of cardiovascular disease (stroke, coronary artery disease (CAD), arrhythmias, and congestive heart failure (CHF)? [If no, then skip to question 21.] 15. Is this request for Saxenda? [If no, then skip to question 18.] 16. Does the patient have family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome (type 2)? 17. Has the patient had an inadequate response or intolerable side effects with at least 3 formulary agents or contraindications to ALL formulary agents? If yes, please list medications tried and reason: [If yes, then skip to question 25.] Reference umber: C6832-A / Effective Date: 03/06/2017 3

4 18. Is this request for Xenical? [If no, then skip to question 24.] 19. Does the patient have any of the following: A) Chronic malabsorption syndrome; B) Cholestasis? 20. Is patient able to adhere to a low fat diet (less than 30 percent of calories from fat)? 21. Has the patient had an inadequate response, intolerable side effects, or a contraindication to Alli (at dose 360mg/day) AD at least TWO other formulary agents? If yes, please list medication tried: [If yes, then go to question 25.] 22. Has the patient had an inadequate response, intolerable side effects, or a contraindication to Alli OR a sympathomimetic (e.g., phentermine, diethylpropion, benzphetamine, phendimetrazine)? [If yes, then skip to question 25.] 23. Has the patient had good response to sympathomimetic however patient has taken the medication for at least 3 months? ote: Use of sympathomimetic beyond 3 months is not recommended. [If yes, then skip to question 25.] 24. Is this request for Alli or a sympathomimetic (e.g., phentermine, diethylpropion, benzphetamine, phendimetrazine)? 25. Will the patient be concurrently using other weight loss medications? Reference umber: C6832-A / Effective Date: 03/06/2017 4

5 26. Is the patient obese with a BMI greater than or equal to 30 kg per square meter? [If yes, then skip to question 28.] 27. Is the patient overweight with a BMI greater than or equal to 27 kg per square meter with one of the following obesity-related chronic diseases and risk factors: A) Coronary heart disease; B) Dyslipidemia (defined as HDL less than 35mg per dl, or LDL greater than or equal to 160mg per dl, or Triglycerides greater than or equal to 400mg per dl); C) Hypertension; D) Diabetes mellitus or prediabetes; E) Sleep apnea; F) Waist circumference of greater than 35 inches (88cm) for women or greater than 40 inches (102cm) for men; G) Polycystic ovary syndrome; H) OA (osteoarthritis)? 28. Will the patient be using the requested drug as an adjunct to caloric restriction and physical activity program? 29. Is the patient pregnant (confirmed by pregnancy test for women of childbearing age) or breastfeeding? Reference umber: C6832-A / Effective Date: 03/06/2017 5

6 30. Does the patient meet the following age requirements: A) If request is for phentermine or Bontril, must be 16 years of age or older; B) If request is for Xenical or Didrex must be 12 years of age or older; C) If request is for Belviq, Tenuate, Contrave, Saxenda or Qsymia must be 18 years of age or older, D) If request is for Alli must be 12 to 16 years of age? 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: C6832-A / Effective Date: 03/06/2017 6