Please ote: Medical ecessity Prior Authorization may be overrided for both formulary coverage and benefit design restrictions. They are issued at the full discretion of the benefit manager. PRIOR AUTHORIZATIO BPASS Tanzeum (albiglutide) Bypass the Prior Authorization by Modifying the following Prescription Forms to the Patient's eeds Drug ame Refer for Diabetes/ Insulin Protocol COMPLETE PRIOR AUTHORIZATIO FORMS: as directed by physician Dx: DIABETES ICD 10: E 11.9 SAMPLE
Prescriber Information Last ame: DEA/PI: Specialty: Phone Fax Member Information Last ame: Member ID umber DOB: Medication Information: Drug ame and Strength: Diagnosis: Quantity and Dosing: Duration: When advised below, please include all requested fax documentation (lab results, etc.) when submitting this Prior Authorization fax form; not submitting requested documentation could delay the clinical review process. Tanzeum Prior Authorization Form ou must answer ALL of the following questions 1. Has the patient had a trial and failure or intolerance to Victoza, Byetta, or Bydureon? Please submit documentation 2. Does the patient have a diagnosis of type 2 diabetes? 3. Is the patient 18 years of age or older? 4. Does the patient have gastroparesis? 5. Has the patient been on this therapy previously? 6. Is the patient s HbA1c greater than 6.9%? HbA1c must be taken within the past 6 months and documentation is required 7. Was the patient s HbA1c greater than 6.9% prior to starting therapy? Documentation is required 8. Has the patient had a trial and an inadequate response or intolerance to a sulfonylurea? 9. Does the patient have a contraindication to therapy with a sulfonylurea (i.e., debilitated state, past history of falls, high risk for falls, hepatic insufficiency)? 10. Is the patient currently taking and will he/she continue to take a sulfonylurea? If no, please provide rationale for discontinuing therapy: 11. Has the patient had a trial and an inadequate response or intolerance to metformin? Page 1 of 3
12. Does the patient have a contraindication to therapy with metformin (i.e., renal insufficiency, hepatic insufficiency)? 13. Is the patient currently taking and will he/she continue to take metformin while on Tanzeum therapy? If no, please provide rationale for discontinuing therapy: 14. Is the patient currently taking any of the following medications? (Please Circle) Precose (acarbose) Byetta, Bydureon (exenatide) Symlin (pramlintide) esina (alogliptin) Jentadueto (linagliptin / metformin) Kombiglyze XR (saxagliptin / metformin) Farxiga (dapagliflozin) Kazano (alogliptin / metformin) Invokamet (canagliflozin / metformin) Trulicity (dulaglutide) Glyset (miglitol) Tradjenta (linagliptin) Xigduo XR (dapagliflozin-metformin) Januvia (sitagliptin) Onglyza (saxagliptin) Oseni (alogliptin / pioglitazone) Victoza (liraglutide) Invokana (canagliflozin) Jardiance (empagliflozin) Janumet/Janumet XR (sitagliptin / metformin) 15. If the patient is taking any of the following medications, will concomitant therapy with those agents be discontinued? Precose (acarbose) Byetta, Bydureon (exenatide) Symlin (pramlintide) esina (alogliptin) Jentadueto (linagliptin / metformin) Kombiglyze XR (saxagliptin / metformin) Farxiga (dapagliflozin) Kazano (alogliptin / metformin) Invokamet (canagliflozin / metformin) Trulicity (dulaglutide) Glyset (miglitol) Tradjenta (linagliptin) Xigduo XR (dapagliflozin-metformin) Januvia (sitagliptin) Onglyza (saxagliptin) Oseni (alogliptin / pioglitazone) Victoza (liraglutide) Invokana (canagliflozin) Jardiance (empagliflozin) Janumet/Janumet XR (sitagliptin / metformin) Please note, not all drugs/diagnoses are covered on all plans. Page 2 of 3
Comments: Information given on this form is accurate as of this date. Prior Authorization forms are located on the Cover Page. Print a new form for each request as forms are updated periodically. Prescriber or Authorized Signature Date Authorized Medical Staff ame/title Attention Healthcare Provider: If you would like to discuss this request with a medical professional, please contact the Prior Authorization Department whose numbers appear on the Cover Page. I understand that USDoctor's use or disclosure of individually identifiable health information, whether furnished by me or obtained by another source such as medical providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996). Page 3 of 3
Contact Information: Telephone: (855)251.9116 Fax: (248)593.9575 Please ote: Medical ecessity Prior Authorization may be utilized to override both formulary coverage and benefit design restrictions. They are issued at the full discretion of the benefit manager. PRIOR AUTHORIZATIO FORM: COVER PAGE Plan Member ID Drug ame Quantity Directions Diagnosis MEMBER IFORMATIO DRUG IFORMATIO Last ame Date of Birth ICD-10 Duration of Therapy PLEASE LIST ALTERATIVE THERAPIES THAT HAVE BEE ATTEMPTED AD A OTHER PERTIET IFORMATIO RELATED TO DRUG AD/OR DISEASE STATE. IF OT PRESET, WITHI ORMAL LIMITS WILL BE USED FOR THE REVIEW. Medication/Failure Reason: IgE: ESR: CRP: # Joints: %BSA: Height: Weight: BMI: HA1C: Hemoglobin: Hematocrit: T-Score: Dialysis: Long Term Care Facility: Self Injecting: Stimulation test: / Growth velocity: #Chemotherapy cycles/month: Mini-Mental Status Test: Baseline Free testosterone/total testosterone: / HCV RA viral load: Viral Genotype: ALT: PHSICIA IFORMATIO Physician Signature Date Physician ame PI # Phone umber Action eeded Only mark Urgent when standard review time would seriously harm the member s life or health or ability to regain maximum function Fax umber Pharmacy Fax Urgent For Review The information contained in this facsimile message, including the attachments, may be privileged, may constitute inside information and is intended only for use of the addressee. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited and may be unlawful. If you have received this communication in error, please immediately notify me by replying to this message and destroy the original message.