2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

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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

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