Prior Authorization Request Form printable pdf download

Alabama Medicaid Pharmacy

Biological Injectables Prior Authorization Request Form

FAX: (800) 748-0116

Fax or Mail to

P.O. Box 3210

Phone: (800) 748-0130

Health Information Designs

Auburn, AL 36823-3210

PATIENT INFORMATION

Patient name

Patient Medicaid #

Patient DOB

Patient phone # with area code

PRESCRIBER INFORMATION

Prescriber name

NPI #

License #

Phone # with area code

Fax # with area code

Address (Optional)

I certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by the Alabama Medicaid Agency. I will be supervising the

patient’s treatment. Supporting documentation is available in the patient record.

Prescribing Practitioner Signature Date

CLINICAL INFORMATION

❒Humira ❒Kineret ❒Myalept ❒Orencia

Drug Requested:

❒ Entyvio

❒Actemra ❒Cimzia

❒Cosentyx

❒Enbrel

❒Remicade

❒SimponI

❒Stelara

NDC/J Code

Strength

Qty.

Days Supply

Current weight:

ICD-9/ICD-10 Code

Number of Refills

Please check the appropriate diagnosis below and answer diagnosis specific questions:

❒Ankylosing spondylitis (AS)

 Is therapy approved by a board certified rheumatologist?

❒ Yes

❒ No

 Has the patient failed a 3 month treatment trial with at least 2 NSAIDs? If yes, attach documentation.

❒ Yes ❒ No

 For symptomatic peripheral arthritis, has the patient failed a 30-day treatment trial with at least one nonbiologic DMARD?

❒ Yes ❒ No

If yes, attach documentation.

❒Crohn’s disease (CD) or ulcerative colitis (UC)

 Is therapy approved by a board certified gastroenterologist?

❒ Yes ❒ No

 Has the patient failed a 30-day treatment trial with at least one or more conventional therapies? If yes, attach documentation.

❒ Yes ❒ No

 For Entyvio, has the patient failed a 30-day treatment trial with at least one of the following: a tumor necrosis factor blocker,

❒ Yes ❒ No

immunomodulator, or corticosteroid? If yes, attach documentation.

❒Generalized Lipodystrophy

 Is the request for treatment of complications of lipodystrophy, liver disease, HIV-related lipodystrophy,

or general obesity not associated with generalized lipodystrophy?

❒ Yes ❒ No

 Is therapy being used as an adjunct to dietary restrictions?

❒ Yes ❒ No

❒Hydradenitis Suppurativa

 Is therapy approved by a board certified dermatologist?

❒ Yes ❒ No

 Has the patient failed a treatment trial with at least one systemic antibiotic in the past 12 months.

❒ Yes ❒ No

❒Juvenile idiopathic arthritis (JIA)

 Is therapy approved by a board certified rheumatologist?

❒ Yes ❒ No

 Has the patient failed a 30-day treatment trial with at least one nonbiologic DMARD? If yes, attach documentation.

❒ Yes ❒ No

❒Plaque psoriasis (PP)

 Is therapy approved by a board certified dermatologist?

❒ Yes ❒ No

 Has the patient failed a 6 month treatment trial with at least 1 topical treatment (generic, OTC, or brand) within the past year?

If yes, attach documentation.

❒ Yes ❒ No

 Has the patient had an inadequate response to phototherapy, systemic retinoids, methotrexate, or cyclosporin?

❒ Yes ❒ No

❒Psoriatic arthritis (PA)

 Is therapy approved by a board certified rheumatologist or dermatologist?

❒ Yes ❒ No

 Has the patient failed a 30-day treatment trial with at least one nonbiologic DMARD? If yes, attach documentation.

❒ Yes ❒ No

❒Rheumatoid arthritis (RA)

 Is therapy approved by a board certified rheumatologist?

❒ Yes ❒ No

 Has the patient failed a 30-day treatment trial with at least one nonbiologic DMARD? If yes, attach documentation.

❒ Yes ❒ No

 For newly diagnosed moderate to severe RA (<6 months), does the patient have high disease activity with features of a poor

prognosis for < 3 months or high disease activity for 3-6 months (without prognostic features) and therapy is being initiated

with methotrexate and a biological injectable? If yes, indicate specific markers, values and features. ___________________

❒ Yes ❒No

 For Actemra, does the patient have moderate to severe RA with an inadequate response to one or more anti-TNFα therapies? ❒ Yes ❒ No

Medical Justification:

DISPENSING PHARMACY INFORMATION

May Be Completed by Pharmacy

Dispensing pharmacy

NPI #

NDC #

Phone # with area code

Fax # with area code

Form 373

Alabama Medicaid Agency

Rev. 10-5-15

Prior Authorization Request Form

Related Articles

Related forms

Related Categories