Dextromethorphan Hbr-Quinidine Sulfate (Nuedexta) - Medical Necessity Request Form printable pdf download

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________

Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________

Horizon NJ Health

Dextromethorphan HBr-Quinidine Sulfate (Nuedexta) – Medical Necessity Request

Contraindication Information:

Please indicate if the member has any of the following contraindications to therapy:

□ Concomitant use with mefloquine (Lariam), quinidine, or quinine

□ History of quinine or mefloquine-induced thrombocytopenia, hepatitis, or other hypersensitivity reactions

□ Concomitant use of monoamine oxidase inhibitors (MAOIs) or within 14 days of MAOI use

□ Prolonged QT interval, congenital long QT syndrome, history suggestive of torsades de pointes, or heart

failure

□ Complete atrioventricular (AV) block without implanted pacemaker, or at high risk of complete AV block

□ Concomitant use with drugs that both prolong QT interval and are metabolized by CYP2D6 [e.g.,

thioridazine (Mellaril) or pimozide (Orap)]

□ NONE

Diagnosis Information:

1. Is the member experiencing Pseudobulbar affect (PBA*)?

Yes or No

a. If no, please provide the member’s diagnosis:

_____________________________

2. What condition is the Pseudobulbar affect (PBA*) associated with?

□ Amyotrophic lateral sclerosis (ALS)

□ Multiple sclerosis (MS)

□ Traumatic brain injury

□ Stroke

□ Alzheimer's disease

□ Parkinson's disease

□ Other: ___________________________________________________________

* PBA is associated with involuntary, sudden, and frequent episodes of laughing and/or crying due to a neurological condition. PBA

episodes typically occur out of proportion or incongruent to the underlying emotional state.

Physician office's signature*_________________________________ Print Name________________________________

*Form must be completed and signed by physician or licensed representative from the physician’s office

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Rev. 03/16

HNJH Fax #: 888-567-0681

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Dextromethorphan Hbr-Quinidine Sulfate (Nuedexta) - Medical Necessity Request Form