Prescriber Information Last Name First Name DEA / NPI Specialty Phone Member Information Last Name Fax - - - - First Name Member ID Number DOB Medication Information: Drug Name and Strength: Quantity: Diagnosis: Dosing: SPORANOX CAPSULES, SPORANOX ORAL SOLUTION, ONMEL, JUBLIA, KERYDIN, CICLOPIROX KIT, CICLODAN SOL KIT, CNL8 NAIL KIT and PEDIPIROX-4 NAIL KIT Prior Authorization Sporanox Capsules Page 1 of 6
1. Will the patient be receiving concurrent therapy with any of the following drugs metabolized by CYP3A4? Methadone Disopyramide Dofetilide Dronedarone Quinidine ergot alkaloids lovastatin simvastatin irinotecan lurasidone oral midazolam pimozide triazolam felodipine nisoldipine ranolazine eplerenone cisapride ticagrelor fesoterodine* telithromycin* solifenacin* colchicine* 2. Does the patient have one of the following diagnoses? (If yes, please circle below.) A) Systemic fungal infection (e.g., aspergillosis, histoplasmosis, blastomycosis) B) Tinea corporis (ringworm) C) Tinea cruris (jock itch) D) Tinea pedis (athlete s foot) E) Tinea capitis (scalp ringworm) F) Pityriasis versicolor G) Onychomycosis Tinea Infection Section 3. Is the patient s condition resistant to topical antifungal therapy? Onychomycosis Section 4. Has the diagnosis of onychomycosis been confirmed by one of the following? A. Positive potassium hydroxide (KOH) preparation B. Culture C. Histology Page 2 of 6
5. Does the patient have one of the following contraindications or exclusions to the use of itraconazole? (If yes, please circle below.) A. Ventricular dysfunction B. Congestive heart failure (CHF) C. History of CHF D. Pregnancy or intent to become pregnant 6. Is the patient s condition causing debility or a disruption in their activities of daily living? 7. Did the patient try and have an inadequate response, intolerance, or hypersensitivity to oral terbinafine therapy? 8. Is the onychomycosis affecting the patient s fingernails, toenails, or both? (Please circle below.) A) Fingernails B) Toenails C) Both (fingernails and toenails) Sporanox Oral Solution 1. Will the patient be receiving concurrent therapy with any of the following drugs metabolized by CYP3A4? Methadone Disopyramide Dofetilide Dronedarone Quinidine ergot alkaloids lovastatin simvastatin irinotecan lurasidone oral midazolam pimozide triazolam felodipine nisoldipine ranolazine eplerenone cisapride ticagrelor fesoterodine* telithromycin* solifenacin* Page 3 of 6
2. Does the patient have one of the following diagnoses? (If yes, please circle below.) A) Systemic fungal infection (e.g., aspergillosis, histoplasmosis, blastomycosis) B) Tinea corporis (ringworm) C) Tinea cruris (jock itch) D) Tinea pedis (athlete s foot) E) Tinea capitis (scalp ringworm) F) Pityriasis versicolor G) Candidiasis (esophageal or oropharyngeal) Tinea Infection Section 3. Is the patient s condition resistant to topical antifungal therapy? Candidiasis (Esophageal or Oropharyngeal) Section 4. Is the candidiasis (esophageal or oropharyngeal) refractory to treatment with fluconazole? Onmel 1. Does the patient have one of the following contraindications or exclusions to the use of itraconazole? (If yes, please circle below.) A. Ventricular dysfunction B. Congestive heart failure (CHF) C. History of CHF D. Pregnancy or intent to become pregnant E. Receiving concurrent therapy with any of the following drugs metabolized by CYP3A4? Cisapride Pimozide Quinidine Dofetilide Levacetylmethadol Felodipine Oral midazolam Nisoldipine Triazolam Lovastatin Simvastatin Ergot alkaloids Methadone 2. Does the patient have a diagnosis of onychomycosis? 3. Has the diagnosis of onychomycosis been confirmed by one of the following? A. Positive potassium hydroxide (KOH) preparation B. Culture C. Histology Page 4 of 6
4. Is the patient s condition causing debility or a disruption in their activities of daily living? 5. Did the patient try and have an inadequate response, intolerance, or hypersensitivity to oral terbinafine therapy? 6. Is the onychomycosis affecting the patient s fingernails, toenails, or both? (Please circle below.) A) Fingernails B) Toenails C) Both (fingernails and toenails) Jublia 1. Does the patient have a diagnosis of onychomycosis of the toenails confirmed by one of the following? A) Positive potassium hydroxide (KOH) preparation B) Culture C) Histology 2. Does the patient have dermatophytomas or lunula (matrix) involvement? 3. Does the patient have mild to moderate disease defined by the presence of all of the following? A) Involvement of at least 1 great toenail B) The target great toenail (TGT) includes at least a 3 mm section of clear nail (measured from the proximal nail fold) and less than or equal to a 3 mm distal toenail plate thickness C) 20% to 50% clinical involvement of the target toenail 4. Has the patient had a trial and inadequate response, intolerance or hypersensitivity to oral terbinafine? 5. Is the patient s condition causing debility or a disruption in their activities of daily living? Kerydin 1. Does the patient have a diagnosis of onychomycosis of the toenails confirmed by one of the following? A) Positive potassium hydroxide (KOH) preparation B) Culture C) Histology 2. Does the patient have dermatophytomas or lunula (matrix) involvement? 3. Does the patient have mild to moderate disease defined by the presence of all of the following? A) Involvement of at least 1 great toenail B) The target great toenail (TGT) includes at least a 3 mm section of clear nail (measured from the proximal nail fold) and less than or equal to a 3 mm distal toenail plate thickness C) 20% to 60% clinical involvement of the target toenail Page 5 of 6
4. Has the patient had a trial and inadequate response, intolerance or hypersensitivity to oral terbinafine? 5. Is the patient s condition causing debility or a disruption in their activities of daily living? Ciclopirox Kit/CNL8 Nail Kit/Pedipirox-4 Nail Kit 1. Does the patient have a diagnosis of onychomycosis of the toenails and/or fingernails that has been confirmed by one of the following? A) Positive potassium hydroxide (KOH) preparation B) Culture C) Histology 2. Does the patient have dermatophytomas or lunula (matrix) involvement? 3. Does the patient have mild to moderate disease defined by the presence of all of the following? A) Involvement of at least 1 great toenail B) The target great toenail (TGT) includes at least a 3 mm section of clear nail (measured from the proximal nail fold) and less than or equal to a 3 mm distal toenail plate thickness C) 20% to 60% clinical involvement of the target toenail 4. Has the patient had a trial and inadequate response, intolerance or hypersensitivity to oral terbinafine? 5. Is the patient s condition causing debility or a disruption in their activities of daily living? Comments: Information given on this form is accurate as of this date. Prescriber or Authorized Signature Date Authorized Medical Staff Name/Title Attention Healthcare Provider: If you would like to discuss this request with a medical professional, please contact the Prior Authorization Department at 800-626-0072. I understand that Catamaran 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 6 of 6