REQUESTED DRUG INFORMATION

Transcription

1 Request for Prior Authorization for Lumizyme (alglucosidase alfa) Website Form Submit request via: Fax All requests for Lumizyme (alglucosidase alfa) require a Prior Authorization and will be screened for medical necessity and appropriateness using the criteria listed below. Lumizyme (alglucosidase alfa) Prior Authorization Criteria: Coverage may be provided with a diagnosis of Pompe Disease (acid α-glucosidase deficiency) and the following criteria is met: The member must have a confirmed diagnosis of Pompe disease either through an enzyme assay demonstrating a deficiency of acid α-glucosidase enzyme activity or DNA testing supporting the diagnosis; AND The medication must be prescribed by a physician who specializes in Pompe disease; AND Documentation of baseline percent predicted forced vital capacity (FVC) and 6-minute walk test; AND The dose does not exceed 20mg/kg body weight administered every2 weeks as an intravenous infusion Initial Duration of Approval: 12 months Reauthorization criteria o The member has tolerated therapy and received a clinical benefit to therapy (e.g. decrease in muscle weakness, improvement in respiratory function, decreased cardiac involvement) ; OR o The member has responded to treatment as defined by improvement in percent predicted FVC and/or 6-minute walk test compared to baseline. Reauthorization Duration of Approval: 12 months

2 LUMIZYME (alglucosidase alfa) PRIOR AUTHORIZATION FORM PROVIDER INFORMATION Requesting Provider: Provider Specialty: Office Address: Office Contact: Office Phone: Office Fax: REQUESTED DRUG INFORMATION Medication: Strength: Frequency: Duration: Is the member currently receiving requested medication? Medication Initiated: Is this medication being used for a chronic or long-term condition for which the medication may be necessary for the life of the patient? Billing Information This medication will be billed: at a pharmacy OR medically (if medically please provide a JCODE: Place of Service: Hospital Provider s office Member s home Other Place of Service Information Name: Address: Phone: Does the member must have a confirmed diagnosis of Pompe disease either through an enzyme assay demonstrating a deficiency of acid α-glucosidase enzyme activity or DNA testing supporting the diagnosis? Please provide the appropriate diagnosis code: Has the member had a baseline percent predicted forced vital capacity (FVC)? Please provide the FVC and the date collected: Has the member had a baseline 6 minute walk test? Please provide 6-minut walk test results and date completed: Does the dose requested exceed 20mg/kg body weight administered every2 weeks? Please provide the dose/frequency requested: Medication Name Strength/ Frequency s of Therapy Status (Discontinued & Why/Current)

3 LUMIZYME (alglucosidase alfa) PRIOR AUTHORIZATION FORM (CONTINUED) PAGE 2 OF 2 Has the member tolerated therapy and received a clinical benefit to therapy as evidenced by one of the following? Please select all that apply to the member: decrease in muscle weakness improvement in respiratory function decreased cardiac involvement improvement in percent predicted FVC improvement in 6-minute walk test compared to baseline

4 DRUG NAME PRIOR AUTHORIZATION FORM PROVIDER INFORMATION Requesting Provider: Provider Specialty: Office Address: Office Contact: Office Phone: Office Fax: REQUESTED DRUG INFORMATION Medication: Strength: Frequency: Duration: Is the member currently receiving requested medication? Medication Initiated: Is this medication being used for a chronic or long-term condition for which the medication may be necessary for the life of the patient? Billing Information This medication will be billed: at a pharmacy OR medically (if medically please provide a JCODE: Place of Service: Hospital Provider s office Member s home Other Place of Service Information Name: Address: Phone: *****Fill in questions as needed****** If you add content to this section that increases the request form to two pages, please have a section on page two that identifies which member the request is being submitted. Medication Name Strength/ Frequency s of Therapy Status (Discontinued & Why/Current) Add questions as needed Has the member experienced a significant improvement with treatment? Please describe:

5 This page is only to be used if the form extends to a second page. DRUG NAME PRIOR AUTHORIZATION FORM (CONTINUED) PAGE 2 OF 2 *****Fill in questions as needed****** If you add content to this section that increases the request form to two pages, please have a section on page two that identifies which member the request is being submitted. Medication Name Strength/ Frequency s of Therapy Status (Discontinued & Why/Current) Add questions as needed Has the member experienced a significant improvement with treatment? Please describe: