TRIPTAN RESTRICTED ACCESS; QUANTITY LIMIT EXCEPTION CERTIFICATION FAX REQUEST FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5 DIGIT Blue Cross NC PROVIDER ID# BELOW PRESCRIBER NAME PRESCRIBER NPI [REQUIRED] Blue Cross NC PROV ID # / TAX ID [out of state] CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX PRESCRIBER ADDRESS CITY STATE ZIP Formulary Drug? Yes No PATIENT NAME Blue Cross NC ID DATE OF BIRTH GENDER REQUEST FOR RESTRICTED ACCESS BRAND TRIPTAN M F Diagnosis Code: 1. Please check the box of the restricted access brand medication you are requesting: RESTRICTED ACCESS MEDICATIONS Alsuma TM Brand Maxalt MLT Tablets* Brand Amerge * Brand Relpax Tablets Brand Axert * Onzetra TM Xsail Brand Frova * Sumavel DosePro Jet-Injector Brand Imitrex * Sumatriptan/Naproxen Brand Imitrex Cartridge* Brand Treximet Tablets Imitrex Injection Zecuity Patch Imitrex or Sumatriptan Pre-Filled Zembrace TM Symtouch Syringe (brand and generic) Brand Imitrex Nasal Spray Brand Zomig Tablets* Brand Imitrex Tablets* Brand Zomig ZMT Tablets* Brand Maxalt Tablets* Zomig Nasal Spray *Generic product within the quantity limit does not require review. 2. Please list medication(s) the patient previously tried and failed, or had an inadequate response related to this diagnosis: Please certify the following by signing and dating below: I certify that I have been authorized to request prior review and certification for the above requested service(s). I further certify that my patient s medical records accurately reflect the information provided. I understand that Blue Cross NC may request medical records for this patient at any time in order to verify this information. I further understand that if Blue Cross NC determines this information is not reflected in my patient s medical records, Blue Cross NC may request a refund of any payments made and/or pursue any other remedies available. Prescriber s Signature (Required): Date: Does the patient require an amount in excess of the quantity limit outlined on pages 3-4 of the Triptan Quantity Limits table for the selected drug above?... Yes No If you answered yes above, complete the questions on page 2, fax and sign both pages 1 and 2. If no, fax page 1 only. For Blue Cross NC members, fax form to 1-800-795-9403 Last Revision Date: November 2017 Page 1
MEDICATION REQUESTED FOR QUANTITY LIMIT EXCEPTION: Please answer the following questions: 1. Please select from the table below the name, strength, and dosage form of the medication you are requesting for a quantity limit exception. Axert (almotriptan) 6.25mg tablet Axert (almotriptan) 12.5mg tablet Maxalt (rizatriptan) 5mg tablet Maxalt (rizatriptan) 10mg tablet Relpax (eletriptan) 20mg tablet Relpax (eletriptan) 40mg tablet Zomig (zolmitriptan) 2.5mg nasal spray Zomig (zolmitriptan) 5mg nasal spray Frova (frovatriptan) 2.5mg tablet Imitrex (sumatriptan) 5mg nasal spray Imitrex (sumatriptan) 20mg nasal spray Imitrex (sumatriptan) 6mg/0.5mL pre-filled syringe Imitrex (sumatriptan) 4mg/0.5mL injection Imitrex (sumatriptan) 6mg/0.5mL injection Imitrex (sumatriptan) 4mg/0.5mL cartridge Imitrex (sumatriptan) 6mg/0.5mL cartridge Zembrace Symtouch 3mg/0.5 ml auto-injector Amerge (naratriptan) 1mg tablet Amerge (naratriptan) 2.5mg tablet Maxalt MLT (rizatriptan ODT) 5mg tablet Maxalt MLT (rizatriptan ODT) 10mg tablet Zomig (zolmitriptan) 2.5mg tablet Zomig (zolmitriptan) 5mg tablet Onzetra Xsail 11mg/Nosepiece Zomig ZMT (zolmitriptan ODT) 2.5mg tablet Zomig ZMT (zolmitriptan ODT) 5mg tablet Treximet (sumatriptan/naproxen) 10mg/60mg tablet Treximet (sumatriptan/naproxen) 85mg/500mg tablet Imitrex (sumatriptan) 25mg tablet Imitrex (sumatriptan) 50mg tablet Imitrex (sumatriptan) 100mg tablet Alsuma (sumatriptan solution) 6mg/0.5mL Imitrex (sumatriptan) 4mg/0.5mL auto-injector Imitrex (sumatriptan) 6mg/0.5mL auto-injector Sumavel DosePro (sumatriptan) 4mg/0.5mL Jet-Injector Sumavel DosePro (sumatriptan) 6mg/0.5mL Jet-Injector Zecuity (sumatriptan) 6.5mg/4hour patch 2. Quantity requested per 90 days: Please answer the following questions: 1. Has the patient tried and failed at least 2 other abortive migraine therapies?... Yes No a. If yes, select the abortive therapies used below: NSAID/COX-2 Inhibitor (Ex. ibuprofen, naproxen, diclofenac, celecoxib, etc.) Ergotamine-containing products (Cafergot, Ergomar, etc) Acetaminophen (Tylenol) 2. Has the patient had > 4 episodes of moderate to severe migraine headaches per month? (Headaches are not considered tension type or chronic daily headaches.)... Yes No 3. For patients experiencing > 4 migraines per month, has prophylactic therapy been given for an adequate trial of at least 2-3 months?... Yes No a. If Yes, please list prophylactic medications tried and failed: 4. Has the possibility of medication-induced, rebound, or chronic daily headaches been considered and ruled out?... Yes No 5. Will the requested medication be dosed concurrently with another triptan product or an ergotcontaining product?... Yes No Please certify the following by signing and dating below: I certify that I have been authorized to request prior review and certification for the above requested service(s). I further certify that my patient s medical records accurately reflect the information provided. I understand that Blue Cross NC may request medical records for this patient at any time in order to verify this information. I further understand that if Blue Cross NC determines this information is not reflected in my patient s medical records, Blue Cross NC may request a refund of any payments made and/or pursue any other remedies available. Prescriber s Signature (Required): Date: For Blue Cross NC members, fax form to 1-800-795-9403 Last Revision Date: November 2017 Page 2
TRIPTAN QUANTITY LIMITS FOR 90 DAYS Medication Dosage Form/Strength Quantity Limit per 90 DAYS Alsuma (sumatriptan solution) 6 mg/0.5 ml 36 doses (18 packages of 2) Amerge (naratriptan) 1 mg tablet 54 tablets (6 packages of 9) Amerge (naratriptan) 2.5 mg tablet 54 tablets (6 packages of 9) Axert (almotriptan) 6.25 mg tablet 36 tablets (6 packages of 6) Axert (almotriptan) 12.5 mg tablet 36 tablets (3 packages of 12) Frova (frovatriptan) 2.5 mg tablet 54 tablets (6 packages of 9) Cartridge Cartridge Injection Sumatriptan solution injection Sumatriptan solution pre-filled syringe for injection Imitrex, Sumatriptan (sumatriptan) Nasal Spray Imitrex, Sumatriptan (sumatriptan) Nasal Spray 4 mg/0.5 ml 36 doses (18 packages) 6 mg/0.5 ml 36 doses (18 packages) 6 mg/0.5 ml 36 doses (18 packages) 4 mg/0.5 ml 36 doses (18 packages) 6 mg/0.5 ml single dose vial (5 x 0.5 ml/package) 15 ml (6 packages) 4 mg/0.5 ml vial 36 doses (36 vials) 6 mg/0.5 ml syringe 36 doses (36 vials) 5 mg 36 units (6 packages of 6) 20 mg 36 units (6 packages of 6) Imitrex (sumatriptan) 25 mg tablet 54 tablets (6 packages of 9) Imitrex (sumatriptan) 50 mg tablet 54 tablets (6 packages of 9) Imitrex (sumatriptan) 100 mg tablet 54 tablets (6 packages of 9) Maxalt (rizatriptan) MLT 5 mg tablet 54 tablets (3 packages of 18) Maxalt (rizatriptan) MLT 10 mg tablet 54 tablets (3 packages of 18) Maxalt (rizatriptan) 5 mg tablet 54 tablets (3 packages of 18) Maxalt (rizatriptan) 10 mg tablet 54 tablets (3 packages of 18) Onzetra Xsail (sumatriptan nasal powder) 11mg / nosepiece 24 doses (3 boxes of 16 nosepieces) Relpax (eletriptan) 20 mg tablet 36 tablets (6 packages of 6) Relpax (eletriptan) 40 mg tablet 36 tablets (6 packages of 6) Sumavel DosePro (sumatriptan) Jet-Injector Sumavel DosePro (sumatriptan) Jet-Injector 4 mg/0.5 ml single dose injection device 6 mg/0.5 ml single dose injection device 36 doses (6 packages of 6) 36 doses (6 packages of 6) Last Revision Date: November 2017 Page 3
Treximet (sumatriptan/naproxen) Treximet (sumatriptan/naproxen) Zecuity (sumatriptan) Iontophoretic Transdermal System 10 mg/60 mg tablet 54 tablets (6 packages of 9) 85 mg/500 mg tablet 54 tablets (6 packages of 9) 6.5 mg/4 hours 36 transdermal systems Zembrace Symtouch 3 mg/0.5ml 36 doses (9 packages of 4) Zomig (zolmitriptan) Nasal Spray Zomig (zolmitriptan) Nasal Spray 2.5 mg/100 microliters 36 units (6 packages of 6) 5 mg/100 microliters 36 units (6 packages of 6) Zomig (zolmitriptan) 2.5 mg tablet 36 tablets (6 packages of 6) Zomig (zolmitriptan) 5 mg tablet 36 tablets (12 packages of 3) Zomig (zolmitriptan) ZMT 2.5 mg tablet 36 tablets (6 packages of 6) Zomig (zolmitriptan) ZMT 5 mg tablet 36 tablets (12 packages of 3) NOTE: quantity limits apply to both brand and generic formulations Non-Discrimination and Accessibility Notice Discrimination is Against the Law Blue Cross and Blue Shield of North Carolina ( Blue Cross NC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross NC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross NC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified interpreters - Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: - Qualified interpreters - Information written in other languages Last Revision Date: November 2017 Page 4
If you need these services, contact Customer Service 1-888-206-4697, TTY and TDD, call 1-800-442-7028. If you believe that Blue Cross NC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Blue Cross NC, PO Box 2291, Durham, NC 27702, Attention: Civil Rights Coordinator- Privacy, Ethics & Corporate Policy Office, Telephone 919-765- 1663, Fax 919-287-5613, TTY 1-888-291-1783 civilrightscoordinator@bcbsnc.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator - Privacy, Ethics & Corporate Policy Office is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. This Notice and/or attachments may have important information about your application or coverage through Blue Cross NC. Look for key dates. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call Customer Service 1-888-206-4697. ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call 1-888-206-4697 (TTY: 1-800-442-7028). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-206-4697 (TTY: 1-800-442-7028). 注意 : 如果您講廣東話或普通話, 您可以免費獲得語言援助服務 請致電 1-888-206-4697 (TTY:1-800-442-7028) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-206-4697 (TTY: 1-800-442-7028). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-888-206-4697 (TTY: 1-800-442-7028) 번으로전화해주십시오. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-206-4697 (ATS : 1-800-442-7028). ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-888-206-4697. المبرقة الكاتبة: 1-800-442-7028. Last Revision Date: November 2017 Page 5
LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-888-206-4697 (TTY: 1-800-442-7028). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-206-4697 (телетайп: 1-800-442-7028). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-206-4697 (TTY: 1-800-442-7028). સ ચન : જ તમ ગ જર ત બ લત હ, ત નન:સ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર 1-888-206-4697 (TTY: 1-800-442-7028). ច ណ ប រស នបរ ប កអ នកន យ យជ ភ ស ខ ម រ បសវ កម ជ ន យខ នកភ ស ម ននតល ជ នសប ម រ ប កអ នកប យម នគ តថ ល ស ម ទ ន ក ទ នងត ម រយ បលម 1-888-206-4697 (TTY: 1-800-442-7028) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-206-4697 (TTY: 1-800-442-7028). ध य न द : यदद आप द न द ब लत त आपक दलए म फ त म भ ष स यत स व ए उपलब ध 1-888-206-4697 (TTY: 1-800-442-7028) पर क ल कर ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ 1-888-206-4697 (TTY: 1-800-442-7028). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます 1-888- 206-4697(TTY: 1-800-442-7028) まで お電話にてご連絡ください Last Revision Date: November 2017 Page 6