Pharmacy Prior Authorization Form - Neighborhood Health Plan Ri
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Customer Service 1-401-459-6020; Fax 1-866-423-0945
Instructions: Please complete this form and fax to: Neighborhood Customer Service at fax # 1-866-423-0945. To review the entire
Neighborhood Formulary, please visit our website at:
Please complete the following information:
Date of Request: ____/_____/_____
Member Name:
Member ID Number, otherwise SSN#:
(required)
(required)
Member Date of Birth:
/
/
Member Sex: M
F
(Circle One)
(required)
Prescriber Name:
Contact Person at Office:
(required)
Prescriber Specialty:
(required)
Office Fax Number:
(
) -
(
)
Tel # & extension:
-
(required)
(required)
Drug Requested: __________________________ Date therapy was initiated ________________________
Provide the following patient information
:
(required)
o When treatment was started: Weight _______ BMI _______
o Current: Height_________ Weight _______ BMI ________
This form is to be used for renewal requests of weight-loss drugs.
Continued coverage after 12 weeks of treatment with a weight-loss drug is dependent on patient response.
Enrollment in, and adherence to, both nutritional counseling and a weight reduction program are required.
*
Literature and current Treatment Guidelines suggest that patients who have not demonstrated at least a 5% weight loss in the first 12 weeks of therapy on a
maximum dose of medication are unlikely to demonstrate a meaningful long-term response.
Assessment of Benefit Need (
Please check all that apply
):
YES
NO
1.
For phentermine only: Patient has lost a minimum of 4 lbs in the first 4 weeks of therapy.
Please provide the weight loss in pounds: ___________lbs (for an additional 12-week coverage approval)
2.
For Qsymia only: Patient has lost at least 3% of body weight in the first 12 weeks of treatment.
Please provide the weight loss in pounds: ___________lbs (for an additional 12-week coverage approval)
(if patient has not lost at least 3% of baseline within 12 weeks on a 7.5mg/46mg dose, therapy should be discontinued
or escalated gradually to the maximum recommended dose for an additional 12 weeks)
3.
For all other drug requests and renewals beyond 24 weeks of therapy: Patient has lost and
maintains a weight loss of at least 5% of body weight from baseline.
Please provide the weight loss in pounds: ___________lbs
3.
Patient continues to be active in weight reduction program.
Provide the name and location of program below.
o Name of weight reduction program: _________________________ Location: ______________
4.
Patient continues to receive mandatory nutritional counseling.
Please provide the name and location of nutritional counseling.
o Name of nutritional counseling program: ______________________ Location: ______________
o Date of patient’s last nutritional counseling appointment: ___________________
Approvals:
up to 6 months at a time,
If criteria are met, weight loss management agents are approvable for
with further renewals based
on further response. Phentermine and diethylpropion are approvable for up to a total of 6 months only since each agent is FDA approved for
short-term use only.
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that
any falsification, omission, or concealment of material fact may subject me to civil or criminal liability.
Prescriber’s Signature____________________________________ NPI_______________ Date ____________
Fax completed form to Neighborhood Customer Service at fax # 1-866-423-0945
Weight Loss Management (renewals) PA Form
Created 12/09; Updated Mar14, Dec15
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