2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
|
|
- Regina Craig
- 5 years ago
- Views:
Transcription
1 Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Botulinum Toxins (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 Botulinum Toxins (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Botox (onabotulinumtoxina) Myobloc (rimabotulinumtoxinb) Other, specify drug Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) 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: Circle the appropriate answer for each question. Question Circle es or o 1. Is the requested drug prescribed by a specialist based on the condition treated? (e.g., neurologist, headache specialist, physical medicine, ophthalmologist, dermatologist) Please indicate specialty: 2. 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 9.] Reference umber: C4395-A / Effective Date: 02/01/2018 1
2 Circle es or o 3. Is this request for Botox? [If no, skip to question 8.] 4. Is the member receiving a cumulative dose of more than 400 units every 90 days? [If yes, then no further questions.] 5. Is this request for Botox for chronic migraine prophylaxis? [If no, skip to question 8.] 6. Has the member s migraine headache frequency reduced by at least 7 days per month (when compared to pre-treatment average) by the end of the initial trial of botulinum toxin therapy? 7. Was the member s migraine headache duration reduced by at least 100 total hours per month (when compared to the pre-treatment average) by the end of the initial trial of botulinum toxin therapy? 8. Has the member had a response to treatment? 9. Is this a request for Botox for treatment of cervical dystonia? [If yes, skip to question 50.] 10.Is this a request for Dysport, Myobloc, or Xeomin for treatment of cervical dystonia? 11.Is this a request for Botox for treatment of blepharospasm? [If yes, skip to question 49.] 12.Is this a request for Xeomin for treatment of blepharospasm? [If no, skip to question 14.] Reference umber: C4395-A / Effective Date: 02/01/2018 2
3 Circle es or o 13. Has the member previously been treated with onabotulinumtoxina (Botox)? [If no, then no further questions] 14.Is this a request for Botox, Xeomin or Dysport for the treatment of chronic limb spasticity? [If no, skip to question 21.] 15.Is the spasticity due to OE of the following: A) hereditary spastic paraplegia, B) spastic hemiplegia due to stroke, traumatic brain or spinal cord injury, or C) multiple sclerosis or other demyelinating disease? 16.Has the member had a trial and failure of baclofen AD at least 1 additional formulary muscle relaxant such as dantrolene or tizanidine? 17.Has the member tried physical and/or occupational therapy? 18.Is there evidence that the abnormal muscle tone is either interfering with functional ability OR is expected to result in joint contracture? 19.Is this a request for Dysport for the treatment of lower limb spasticity? [If no, skip to question 51.] 20.Is the member at least 2 years old? 21.Is this a request for Botox for treatment of sialorrhea (excessive secretion of saliva, drooling)? [If no, skip to question 23.] 22.Is the member at least 21 months old? Reference umber: C4395-A / Effective Date: 02/01/2018 3
4 Circle es or o [If yes, skip to question 25.] 23.Is this a request for Myobloc for treatment of sialorrhea (excessive secretion of saliva, drooling)? [If no, skip to question 27.] 24.Is the member at least 18 years old? 25.Has the member had a trial and failure of glycopyrrolate and benztropine? 26.Does the member have significant complications due to sialorrhea such as chronic skin maceration or infections? 27.Is this a request for Myobloc or Xeomin? [If yes, then no further questions.] 28.Is this a request for Botox for treatment of strabismus in a member with deviations of less than 50 prism diopters? [If yes, skip to question 49.] 29.Is this a request for Botox for treatment of hemifacial spasm? 30.Is this a request for Botox for chronic migraine prophylaxis? [If no, skip to question 33.] 31.Is therapy being requested for prevention of chronic migraine in a member who experiences migraines more than 15 days per month with headaches lasting 4 hours a day or longer? Reference umber: C4395-A / Effective Date: 02/01/2018 4
5 Circle es or o 32.Has the member had an inadequate response to or intolerable side effects with at least 3 medications from TWO classes of migraine headache prophylaxis medications for at least 2 months (60 days): A) Beta-blocker: propranolol, metoprolol, timolol, atenolol, nadolol, B) Anticonvulsant: valproic acid, divalproex, topiramate, C) Antidepressants: amitriptyline, venlafaxine 33.Is this a request for Botox for the treatment of neurogenic bladder? [If no, skip to question 36.] 34.Has the member had a trial and failure of 2 formulary urinary anticholinergics (e.g., oxybutynin, trospium, tolterodine)? _ 35.Has the member had a trial and failure of behavioral therapy (e.g., bladder training or pelvic floor exercises)? 36.Is this a request for Botox for the treatment of overactive bladder? [If no, skip to question 39.] 37.Has the member had a trial and failure of 3 formulary urinary anticholinergics (e.g., oxybutynin, trospium, tolterodine)? 38.Has the member had a trial and failure of behavioral therapy (e.g., bladder training or pelvic floor exercises)? Reference umber: C4395-A / Effective Date: 02/01/2018 5
6 Circle es or o 39.Is this a request for Botox for the treatment of esophageal achalasia? [If no, skip to question 42.] 40.Does the member meet OE of the following: A) Member remains symptomatic despite surgical myotomy or pneumatic dilation, B) Member is not a candidate for surgical myotomy or pneumatic dilation or refuses procedure(s), or C) Member presents with atypical achalasia symptoms and Botox is needed to help guide therapy and/or confirm diagnosis Please indicate which applies to the member: _ [If no, then no further questions] 41.Has malignancy at the esophagogastric junction been ruled out by endoscopic evaluation? 42.Is this a request for Botox for treatment of chronic anal fissures? [If no, skip to question 44.] 43.Has the member had a trial and failure of nitroglycerin ointment 0.4% (Rectiv) AD either bulk fiber supplements, stool softeners, or sitz baths for at least 1 month? List treatments tried and reason for failure: _ 44. Is this a request for Botox for treatment of severe primary axillary hyperhidrosis (axillae, palms or soles)? [If no, skip to question 47.] 45.Does the member have medical complications from hyperhidrosis such as skin maceration with secondary skin infections? Reference umber: C4395-A / Effective Date: 02/01/2018 6
7 Circle es or o 46.Has the member had a trial and failure of topical aluminum chloride 20%? 47. Is this a request for Botox or Dysport for management of spasticity or equinus gait (tiptoeing) in a member 2-18 years of age with cerebral palsy? 48.Will the member be enrolled in, or is the member currently being managed with, occupational therapy? 49.Is the member at least 12 years old? 50.Is the member at least 16 years old? 51.Is the member at least 18 years old? 52.Are treatments scheduled at least 12 weeks apart? 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: C4395-A / Effective Date: 02/01/2018 7
Circle Yes or No Y N. [If yes, no further questions.]
02/18/2016 Prior Authorization AETA BETTER HEALTH PE MEDICAID & AETA BETTER HEALTH KIDS Botulinum Toxins (PA88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization AETA BETTER HEALTH MICHIGA Botulinum Toxins (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information[If yes, no further questions.]
05/30/2014 Prior Authorization AETA BETTER HEALTH OF ILLIOIS MEDICAID Botox (IL88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More informationAetna Better Health of Virginia
Botox (onabotulinumtoxina) Myobloc (rimabotulinumtoxinb) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Indications: (use if necessary): Overactive Bladder BOTOX indicated for the treatment
More informationNeuromuscular Blocking Agents
Neuromuscular Blocking Agents DRUG POLICY This Prior Authorization request will be reviewed for medical necessity only. Benefits are subject to the terms and conditions of the patient s contract. Please
More informationBotox. Botox (onabotulinum toxin A) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.75.01 Subject: Botox Page: 1 of 8 Last Review Date: September 15, 2017 Botox Description Botox (onabotulinum
More informationDrug Name (select from list of drugs shown / provide drug information) Patient Information. Prescribing Physician
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 /
More informationBotulinum Toxins. Length of Authorization: From 90 days to 12 months
Botulinum Toxins Goal(s): Approve botulinum toxins for funded OHP conditions supported by evidence of benefit (eg, dystonia or spasticity associated with certain neurological diseases). Require positive
More informationBotox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb)
Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date:
More informationHARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
Generic Brand HICL GCN Exception/Other ONABOTULINUMTOXINA BOTOX 04867 BRAND BOTOX COSMETIC ABOBOTULINUMTOXINA DYSPORT 36477 RIMABOTULINUMTOXINB MYOBLOC 21869 INCOBOTULINUMTOXINA XEOMIN 36687 Please use
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Botulinum Toxins Reference Number: TCHP.PHAR.1812 Effective Date: 07.01.2018 Last Review Date: 04.13.2018 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the
More informationBotulinum toxins: abobotulinumtoxina (Dysport ), incobotulinumtoxina (Xeomin ), onabotulinumtoxina (Botox ), & rimabotulinumtoxinb (Myobloc )
Botulinum toxins: abobotulinumtoxina (Dysport ), incobotulinumtoxina (Xeomin ), onabotulinumtoxina (Botox ), & rimabotulinumtoxinb (Myobloc ) These services may or may not be covered by your HealthPartners
More information2. Does the patient have a diagnosis of Crohn s disease? Y N
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Stelara (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationBotox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb)
Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective
More information2. Is the patient responding to medication? Y N
Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS ADD-ADHD Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationTable of Contents. 1.0 Description of the Procedure, Product, or Service Safety and Provider Compliance... 1
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Safety and Provider Compliance... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific...
More informationOffice Phone: * Cigna ID: * Date of Birth: Office Street Address: City: State: Zip:
Phone: (800) 244-6224 Fax: (855) 840-1678 Botox (botulinum toxin type A) Notice: Please be sure to complete this form in its entirety. Missing information makes it difficult to approve requests and creates
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Anticoagulant Injectable (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationBOTOX. Description. Section: Prescription Drugs Effective Date: January 1, 2013 Subsection: CNS Original Policy Date: December 7, 2011
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.12.01 Subject: Botox Page: 1 of 6 Last Review Status/Date: December 6, 2012 BOTOX Description Botox (onabotulinum
More informationPrior Authorization Update: Botulinum Toxins
Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
More informationPharmacy Prior Authorization
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
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization AETA BETTER HEALTH ILLIOIS (MEDICAID) CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information2. Is this request for a preferred medication? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationMedication Prior Authorization Form
(OnabotulinumtoxinA) Dysport (abobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Xeomin (incobotulinumtoxina) Policy Number: 1042 Policy History Approve Date: 12/11/2015 Revise Dates: 7/7/2016 Next Review:
More informationCircle Yes or No Y N. [If no, then no further questions.]
01/04/2016 Prior Authorization MERC MARICOPA ITEGRATED CARE - TXIX/XXI SMI (MEDICAID) Multiple Sclerosis Agents (AZ88) This fax machine is located in a secure location as required by HIPAA regulations.
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization AETA BETTER HEALTH VIRGIIA Multiple Sclerosis Agents (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationMedication Prior Authorization Form
(OnabotulinumtoxinA) Dysport (abobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Xeomin (incobotulinumtoxina) Policy Number: 1042 Policy History Approve Date: 12/11/2015 Revise Dates: 07/07/2017 Next Review:
More information2. Does the patient have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)?
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
More informationCircle Yes or No Y N. [If yes, skip to question 30.] 2. Is this request for a child? Y N. [If no, skip to question 20.]
05/20/2015 Prior Authorization MERC CARE PLA (MEDICAID) Growth Hormone (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More information3. Has the patient had a sustained improvement in Pain or Function (e.g. PEG scale with a 30 percent response from baseline)?
Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationClinical Policy: OnabotulinumtoxinA (Botox) Reference Number: ERX.SPMN.216
Clinical Policy: (Botox) Reference Number: ERX.SPMN.216 Effective Date: 01/17 Last Review Date: Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More information3. Does the patient continue to receive nutritional or psychological counseling? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information3. Does the patient meet ALL of the following requirements? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA Procrit - Retacrit (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information3. Does the patient have a diagnosis of rheumatoid arthritis (RA) with moderate to high disease activity?
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Enbrel (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationCircle Yes or No Y N. [If no, skip to question 8.] 2. Has the patient been compliant with therapy as verified by the prescriber?
06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Tecfidera (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationLinks in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website.
Local Coverage Determination (LCD): Drugs and Biologicals: Botulinum Toxins (L34253) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information
More information3. Has the member received the requested drug for less than 2 years? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Zoladex (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization MERC CARE (MEDICAID) Multiple Sclerosis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More informationThis policy addresses only onabotulinumtoxina, commercially available as Botox.
OnabotulinumtoxinA DESCRIPTION Botulinum toxin, produced by the bacterium Clostridium botulinum, is one of the most potent naturally occurring neurotoxins known. It induces chemodenervation by first binding
More informationBotox. Botox (onabotulinum toxin A) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.75.01 Subject: Botox Page: 1 of 10 Last Review Date: November 30, 2018 Botox Description Botox (onabotulinum
More information3. Has the member received the requested drug for less than 2 years? Y N
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
More information3. Has the patient shown improvement in signs and symptoms of the disease? Y N
Pharmacy Prior Authorization MERC CARE (MEDICAID) Orencia (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed
More information3. Have baseline A1c or fasting glucose, thyroid-stimulating hormone (TSH), and electrocardiography (EKG) been checked?
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Somatostatin Analogs (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Does the patient have chronic urticaria? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Xolair (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information2. Is the patient responding to Remicade therapy? Y N
09/29/2015 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Remicade (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information2. Did the member receive this medication during a recent hospitalization? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Did the patient receive this medication during a recent hospitalization? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationBOTULINUM TOXIN POLICY TO INCLUDE:
BOTULINUM TOXIN POLICY TO INCLUDE: Blepharospasm in adults, Hemi facial spasm in adults, spasmodic torticollis (cervical dystonia), focal spasticity treatment of dynamic equinus foot deformity, focal spasticity
More informationThis policy addresses only the type A formulation abobotulinumtoxina marketed as Dysport.
AbobotulinumtoxinA NDC CODE(S) 00299-5962-xx Dysport 300 UNIT VIAL (GALDERMA LABORA) 15054-0500-XX Dysport 500 UNIT SOLR (IPSEN BIOPHARMACEUTICALS) 15054-0530-XX Dysport 300 UNIT SOLR (IPSEN BIOPHARMACEUTICALS)
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization MERC CARE (MEDICAID) Colony Stimulating Factors (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information3. Did the patient show evidence of remission by week 8 of Humira Y N therapy?
09/23/2015 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationClinical Policy: Botulinum Toxins Reference Number: NE.PHAR.15
Clinical Policy: Reference Number: NE.PHAR.15 Effective Date: 01/01/2017 Last Review Date: Revision Log See Important Reminder at the end of this policy for important regulatory and legal information.
More informationCircle Yes or No Y N. [If yes, skip to question 29.] 2. Is the request for Sandostatin LAR? Y N. [If no, skip to question 5.] Prior Authorization
04/03/2016 Prior Authorization MERC MARICOPA ITEGRATED CARE - TXIX/XXI SMI (MEDICAID) Somatostatin Analogs and Somavert (AZ88) This fax machine is located in a secure location as required by HIPAA regulations.
More information3. Does the member continue to receive nutritional or psychological counseling?
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Does the member have a diagnosis of central precocious puberty? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Leuprolide (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationClinical Policy: OnabotulinumtoxinA (Botox) Reference Number: CP.PHAR.232
Clinical Policy: (Botox) Reference Number: CP.PHAR.232 Effective Date: 07/16 Last Review Date: 05/16 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More informationAbbreviated Class Review: Botulinum toxins
Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35, Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
More information2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Multiple Sclerosis Agents (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information2. Is the request for Alli, Xenical or Belviq? Y N. 3. Has the patient received 6 months or more of therapy? Y N
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.
More informationCircle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.
06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information3. Has the patient shown improvement in signs and symptoms of the disease? Y N
Pharmacy Prior Authorization MERC CARE (MEDICAID) Renflexis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationPharmacy Medical Necessity Guidelines: Botulinum Toxins
Pharmacy Medical Necessity Guidelines: Effective: January 1, 2018 Effective: Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical
More information[If no, skip to question 10.] Y N. 2. Does the member have a diagnosis of Paget s disease of bone? Y N. [If no, skip to question 4.
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Zoledronic Acid (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information3. Has bone specific alkaline phosphatase level increased OR does the member have symptoms related to active Paget s?
Pharmacy Prior Authorization AETA BETTER HEALTH VIRGIIA CCC PLUS and MEDALLIO/FAMIS 4.0 Zoledronic Acid (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Does the patient have a diagnosis of giant cell arteritis (GCA)? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Actemra (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationThis policy addresses only onabotulinumtoxina, commercially available as Botox.
OnabotulinumtoxinA DESCRIPTION Botulinum toxin, produced by the bacterium Clostridium botulinum, is one of the most potent naturally occurring neurotoxins known. It induces chemodenervation by first binding
More information3. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing for giant cell arteritis?
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Actemra (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Enbrel (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More information1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)?
09/07/2016 Prior Authorization AETA BETTER HEALTH OF KETUCK (MEDICAID) PCSK9 Inhibitors (K88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information2. Does the patient have a diagnosis of ulcerative colitis or Crohn s? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH LOUISIAA (MEDICAID) Remicade (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationNeurotoxins (Botox, Dysport, Myobloc and Xeomin )
Last Review Date: November 10, 2017 Number: MG.MM.PH.01mC Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth
More informationBotulinum Toxin Medical Policy Prior Authorization Program Summary
OBJECTIVE The intent of the botulinum toxin medical drug criteria is to ensure appropriate selection of patients for treatment according to product labeling and/or clinical studies and/or guidelines and
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More information2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Multiple Sclerosis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationPrior Authorization. Drug Name (select from list of drugs shown) Gilenya (fingolomid) Quantity Frequency Strength. Physician Name:
06/01/2016 Prior Authorization Aetna Better Health Michigan Gilenya This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed
More informationClinical Policy: OnabotulinumtoxinA (Botox) Reference Number: ERX.SPA.192 Effective Date:
Clinical Policy: (Botox) Reference Number: ERX.SPA.192 Effective Date: 01.11.17 Last Review Date: 11.17 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More information2. Has the patient had a response to treatment? Y N. 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? Y N
12/21/2016 Prior Authorization Aetna Better Health of West Virginia Humira (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More informationScientific Update Laxman Bahroo, MD
Scientific Update Laxman Bahroo, MD Associate Professor Director; Botulinum Toxin Clinic Director; Neurology Residency Program Medstar Georgetown University Hospital Washington, D.C. Disclosures Advisory
More information1. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Eligard Trelstar - Vantas (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationCalcitonin Gene Related Peptide Receptor Inhibitors Prior Authorization Criteria:
Request for Prior Authorization for Calcitonin Gene Related Peptide Receptor Inhibitors Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for Calcitonin Gene
More informationCLINICAL MEDICATION POLICY
CLINICAL MEDICATION POLICY Policy Name: Botox (onabotulinumtoxina) Policy Number: Approved By: Medical Management, Clinical Pharmacy Revision Date: 12/11/2017 Products: Highmark Health Options Application:
More informationCircle Yes or Y N. [Note: requests without this information will not be accepted.] [If no, then no further questions.
10/01/2016 Prior Authorization Aetna Better Health of West Virginia COLO STIMULATIG FACTORS (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist?
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Colony Stimulating Factors (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationSee Policy CPT/HCPCS CODE section below for any prior authorization requirements
Effective Date: 4/1/2017 Section: MED Policy No.: 209 Medical Officer 4/1/2018 Date Technology Assessment Committee Approved Date: 4/09;6/10, 01/11; 5/13; 2/15 Medical Policy Committee Approved Date: 11/09;
More informationPlease submit supporting medical documentation, notes and test results.
Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA Valcyte (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date.
More informationDRUG USE EVALUATION: UTILIZATION OF BOTULINUM TOXIN
There are currently four botulinum toxin (BoNT) products available in the United States: abobotulinumtoxina (ABO), incobotulinumtoxina (INC), onabotulinumtoxina (ONA), and rimabotulinumtoxinb (RIM). They
More informationPolicy. Medical Policy Manual Approved Revised: Do Not Implement Until 4/2/19. IncobotulinumtoxinA
IncobotulinumtoxinA NDC CODE(S) 00259-1605-XX Xeomin 50 UNIT SOLR (MERZ PHARMACEUTICAL) 00259-1610-XX Xeomin 100 UNIT SOLR (MERZ PHARMACEUTICAL) 00259-1620-XX Xeomin 200 UNIT SOLR (MERZ PHARMACEUTICAL)
More informationBOTULINUM TOXINS A AND B
BOTULINUM TOXINS A AND B UnitedHealthcare Community Plan Medical Benefit Drug Policy Policy Number: CS2018D0017S Effective Date: January 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 BENEFIT
More informationBOTULINUM TOXINS A AND B
DRUG POLICY BOTULINUM TOXINS A B Policy Number: 2014D0017N Effective Date: 9/1/2014 Table of Contents Page COVERAGE RATIONALE... 1 BENEFIT CONSIDERATIONS... 7 BACKGROUND... 8 CLINICAL EVIDENCE... 8 U.S.
More informationBotulinum Toxins (BOTOX, DYSPORT, MYOBLOC and XEOMIN)
Botulinum Toxins (BOTOX, DYSPORT, MYOBLOC and XEOMIN) Policy Number: Original Effective Date: MM.04.004 03/14/2006 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 10/01/2013 Section: Prescription
More informationCircle Yes or No Y N. (Note: requests without this information will not be accepted.) [If no, then no further questions.]
04/25/2016 Prior Authorization AETA BETTER HEALTH OF LA MEDICAID Colony Stimulating Factors (LA88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationBotulinum Toxin. When Policy Topic is covered The use of botulinum toxin may be considered medically necessary for the following:
Botulinum Toxin Policy Number: 5.01.05 Last Review: 01/2018 Origination: 02/1998 Next Review: 02/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for botulinum toxin
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: botulinum_toxin_injection 8/1985 10/2017 10/2018 10/2017 Description of Procedure or Service Description
More informationClinical Policy Title: Botulinum toxin products
Clinical Policy Title: Botulinum toxin products Clinical Policy Number: 00.02.02 Effective Date: September 1, 2013 Initial Review Date: May 13, 2013 Most Recent Review Date: May 19, 2017 Next Review Date:
More informationOriginal Policy Date
MP 5.01.03 Botulinum Toxin Medical Policy Section Prescription Drug Issue 12:2013 Original Policy Date 12:2013 Last Review Status/Date Reviewed with literature search/12:2013 Return to Medical Policy Index
More informationBOTULINUM TOXINS A AND B
BOTULINUM TOXINS A AND B UnitedHealthcare Commercial Medical Benefit Drug Policy Policy Number: 2018D0017S Effective Date: January 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 BENEFIT CONSIDERATIONS...
More information2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Growth Hormone (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More information