Pharmacy Prior Authorization

Similar documents
3. Has the member received the requested drug for less than 2 years? Y N

2. Is this request for a preferred medication? Y N

2. Is the patient responding to medication? Y N

[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

3. Does the patient meet ALL of the following requirements? Y N

3. Has the member received the requested drug for less than 2 years? Y N

2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist?

Pharmacy Prior Authorization

2. Does the patient have a diagnosis of giant cell arteritis (GCA)? Y N

3. Have baseline A1c or fasting glucose, thyroid-stimulating hormone (TSH), and electrocardiography (EKG) been checked?

3. Has the patient had a sustained improvement in Pain or Function (e.g. PEG scale with a 30 percent response from baseline)?

2. Does the patient have a diagnosis of Crohn s disease? Y N

3. Has bone specific alkaline phosphatase level increased OR does the member have symptoms related to active Paget s?

2. Does the member have a diagnosis of central precocious puberty? Y N

Pharmacy Prior Authorization

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

Circle Yes or No Y N. [If no, skip to question 8.] 2. Has the patient been compliant with therapy as verified by the prescriber?

Pharmacy Prior Authorization

2. Did the patient receive this medication during a recent hospitalization? Y N

2. Did the member receive this medication during a recent hospitalization? Y N

Pharmacy Prior Authorization

2. Is the patient responding to Remicade therapy? Y N

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

3. Does the patient continue to receive nutritional or psychological counseling? Y N

2. Does the patient have a diagnosis of ulcerative colitis or Crohn s? Y N

Pharmacy Prior Authorization

Circle Yes or No Y N. (Note: requests without this information will not be accepted.) [If no, then no further questions.]

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

2. Does the patient have chronic urticaria? Y N

3. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing for giant cell arteritis?

2. Does the patient have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)?

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

3. Did the patient show evidence of remission by week 8 of Humira Y N therapy?

Circle 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.

Circle Yes or Y N. [Note: requests without this information will not be accepted.] [If no, then no further questions.

3. Has the patient shown improvement in signs and symptoms of the disease? Y N

3. Does the member continue to receive nutritional or psychological counseling?

Circle Yes or No Y N. [If no, then no further questions.]

3. Does the patient have a diagnosis of rheumatoid arthritis (RA) with moderate to high disease activity?

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

Please submit supporting medical documentation, notes and test results.

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

SAVAYSA (edoxaban tosylate) oral tablet

Circle 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.]

[If yes, no further questions.]

Circle Yes or No Y N. [If yes, no further questions.]

Prior Authorization. Drug Name (select from list of drugs shown) Gilenya (fingolomid) Quantity Frequency Strength. Physician Name:

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

Circle 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

3. Has the patient shown improvement in signs and symptoms of the disease? Y N

Pharmacy Prior Authorization

2. Has the patient had a response to treatment? Y N. 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? Y N

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

Clinical Policy: Dalteparin (Fragmin) Reference Number: ERX.SPA.207 Effective Date:

Pharmacy Prior Authorization

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

Circle Yes or No Y N. [If yes, skip to question 13 REAUTHORIZATION REQUESTS]

Clinical Policy: Dalteparin (Fragmin) Reference Number: ERX.SPA.207 Effective Date:

Prior Authorization. Drug Name (select from list of drugs shown) Viekira Pak (ombitasv-paritaprev-ritonav-dasabuv) Quantity Frequency Strength

2. Is the request for Humatrope? Y N [If no, skip to question 6.]

THROMBOSIS RISK FACTOR ASSESSMENT

Drug Name (specify drug) Quantity Frequency Strength

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Drug Name (specify drug) Quantity Frequency Strength

Drug Name (specify drug) Quantity Frequency Strength

DEEP VEIN THROMBOSIS (DVT): TREATMENT

Title: Low Molecular Weight Heparins (LMWH), fondaparinux (Arixtra)

Clinical Policy: Dalteparin (Fragmin) Reference Number: CP.PHAR.225

Prior Authorization. Physician Name: Specialty: NPI Number: Physician Fax: Physician Phone: Physician Address: City, State, Zip:

Prostate Biopsy Alerts

Mabel Labrada, MD Miami VA Medical Center

I. UNIFORM FORMULARY REVIEW PROCESS

Venous Thromboembolism National Hospital Inpatient Quality Measures

9/9/2016. Drug Name (select from list of drugs shown) Bunavail Buccal Film (buprenorphinenaloxone) Suboxone Sublingual Film (buprenorphine-naloxone)

Disclosures. DVT: Diagnosis and Treatment. Questions To Ask. Dr. Susanna Shin - DVT: Diagnosis and Treatment. Acute Venous Thromboembolism (VTE) None

Potpourri of Hematology Oncology. Jasmine Nabi, M.D. Oncology Associates Hall-Perrine Cancer Center at Mercy

Oral Anticoagulation Drug Class Prior Authorization Protocol

NEWSLETTER DUE CARE PROGRAM. WINTER 2014 Summer 2015 COMMONLY ASKED QUESTION:

Drug Class Review Newer Oral Anticoagulant Drugs

VENOUS THROMBOEMBOLISM: DURATION OF TREATMENT

Drug Use Criteria: Direct Oral Anticoagulants

Lovenox to xarelto The Borg System is 100 % Retrievable & Reusable Lovenox to xarelto

Pradaxa (dabigatran)

DVT PROPHYLAXIS IN HOSPITALIZED MEDICAL PATIENTS SAURABH MAJI SR (PULMONARY,MEDICINE)

Anticoagulation Overview Jed Delmore, MD, FACS, FACOG Professor Obstetrics and Gynecology University of Kansas School of Medicine, Wichita

Low-Molecular-Weight Heparin

Dr. Riaz JanMohamed Consultant Haematologist The Hillingdon Hospital Foundation Trust

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. A. Prescriptions That Require Prior Authorization

Duration of Anticoagulant Therapy. Linda R. Kelly PharmD, PhC, CACP September 17, 2016

Slide 1. Slide 2. Slide 3. Outline of This Presentation

DVT - initial management NSCCG

Low-Molecular-Weight Heparin

Xarelto (rivaroxaban)

Anticoagulation for prevention of venous thromboembolism

Updates in Medical Management of Pulmonary Embolism and Deep Vein Thrombosis. By: Justin Youtsey, Elliott Reiff, William Montgomery, Grant Finlan

Transcription:

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 information, sign and date. Fax signed forms to Aetna Better Health ew Jersey at 1-855-296-0323. When conditions are met, we will authorize the coverage of Anticoagulant Injectable (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) enoxaparin Fragmin (dalteparin) fondaparinux Iprivask (desirudin) Other, specify drug 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. Has the plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? If yes, please provide the following: Rationale for continued treatment: Anticipated length of therapy: Indication: _ Recent international normalized ratio (IR) if on warfarin: Reference umber: C7036-A / Effective Date: 12/01/2018 1

Circle es or o 2. Is the request for a non-formulary agent? [If no, then skip to question 6.] 3. Has the member experienced an inadequate response, intolerance, or contraindication to enoxaparin? [If no, then no further questions.] 4. Is this request for Iprivask? [If no, then skip to question 6.] 5. Is the requested drug being prescribed for deep vein thrombosis (DVT) prophylaxis for a member with a hip replacement? [o further questions.] 6. Is the requested drug being prescribed for PROPHLAXIS of venous thromboembolism (VTE) (prevention of deep vein thrombosis (DVT) or pulmonary embolism (PE))? [If no, then skip to question 17.] 7. Is the requested drug being prescribed for a member in a high risk pregnancy (for example, homozygous for factor V Leiden deficiency, Prothrombin Mutation 20210 or a family history of venous thromboembolism (VTE))? Please provide member s estimated due date: The duration of approval is based on the due date of the pregnancy plus 6 weeks. 8. Is the requested drug being prescribed in a member with cancer and solid tumors who is at high risk of thrombosis (for example, previous venous thromboembolism (VTE), immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide, or lenalidomide)? 9. Is the requested drug being prescribed in a member with cancer who is undergoing surgery? 10.Is the requested drug being prescribed in a member undergoing hip or knee replacement or hip fracture surgery? Reference umber: C7036-A / Effective Date: 12/01/2018 2

Please document date of surgery: Circle es or o 11.Is the requested drug being prescribed for bridge therapy for perioperative warfarin discontinuation? Please provide surgery date (if applicable): 12.Is the requested drug being prescribed in a member with restricted mobility during acute illness? 13. Is the requested drug being prescribed in a member undergoing abdominalpelvic or general surgery and is at moderate to high risk for venous thromboembolism (VTE)? If yes, please provide date of surgery: 14.Is the requested drug being prescribed in a member who has had recent major trauma (for example, traumatic brain injury (TBI) or spinal cord injury)? 15.Is the requested drug being prescribed in a member with atrial fibrillation who will be undergoing cardioversion? If yes, please provide date of cardioversion: _ 16.Is the requested drug being prescribed in a member with acute ischemic stroke and has restricted mobility? [o further questions.] 17.Is the requested drug being prescribed for TREATMET of venous thromboembolism (VTE) (treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE))? [If no, then no further questions.] 18.Is the requested drug being prescribed in a member with cancer and high bleeding risk? Reference umber: C7036-A / Effective Date: 12/01/2018 3

Circle es or o 19.Is the requested drug being prescribed in a member with cancer and low to moderate bleeding risk? 20. Is the requested drug being prescribed for long-term treatment in a noncancer member who has had a trial and failure with warfarin and Eliquis or Xarelto? 21.Is the requested drug being prescribed for a member who recently started warfarin until the international normalized ratio (IR) is in therapeutic range for at least 5 days? 22.Is the requested drug being prescribed in a member with a high risk pregnancy? Please provide member s estimated due date: The duration of approval is based on the due date of the pregnancy plus 6 weeks. 23.Is the requested drug being prescribed in a member with recurrent venous thromboembolism (VTE) that occurred while taking oral anticoagulants? 24.Is the requested drug being prescribed to treat superficial vein thrombosis (SVT) of the lower limb? 25.Is the requested drug being prescribed to treat an acute upper-extremity deep vein thrombosis (UEDVT) that involves the axillary or more proximal veins? 26.Is the requested drug being prescribed to treat Provoked venous thromboembolism (VTE)? Reference umber: C7036-A / Effective Date: 12/01/2018 4

Circle es or o 27.Is the requested drug being prescribed to treat Unprovoked venous thromboembolism (VTE) in a member with high bleeding risk? 28.Is the requested drug being prescribed to treat Unprovoked venous thromboembolism (VTE) in a member with low to moderate bleeding risk? 29.Is the requested drug being prescribed for bridge therapy with warfarin? 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: C7036-A / Effective Date: 12/01/2018 5

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback