Dupixent Prior Authorization Request Form printable pdf download

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Please note: All information below is required to process this request.

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Dupixent

Prior Authorization Request Form (Page 1 of 2)

DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

Member Information

Provider Information

(required)

Member Name:

Provider Name:

Insurance ID#:

NPI#:

Specialty:

Date of Birth:

Office Phone:

Street Address:

Office Fax:

City:

State:

Zip:

Office Street Address:

Phone:

City:

State:

Zip:

Medication Information

(required)

Medication Name:

Strength:

Dosage Form:

Continuation of therapy?  Yes  No If “YES”, answer the following:

Directions for Use:

Has member been on this medication in the last 180 days?*  Yes  No

Does the prescriber confirm that the medication has been effective in

 Check if requesting brand

treating the member’s medical condition?*  Yes  No

Clinical Information

(required)

Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses OptumRx for certain pharmacy benefit services. Your patient’s

benefit plan requires that we review certain requests for coverage with the prescribing physician. This includes requests for benefit coverage beyond plan

specifications. Please complete the following questions and then fax this form to the toll free number listed below. Upon receipt of the completed form,

prescription benefit coverage will be determined based on the benefit plan’s rules.

Select the diagnosis below:

 Moderate to severe chronic atopic dermatitis

Other: _______________________________________________________ ICD-10 code(s): __________________________________

Clinical Information:*

Select the member ‘s disease severity based on physician assessment:

 Moderate

 Severe

Select if the member have disease history that has required systemic immunosuppressive therapy for control with the following

medications: (Please provide dates of use)

 Cyclosporine

Date of use: _____________________________________

 Azathioprine

Date of use: _____________________________________

 Methotrexate

Date of use: _____________________________________

 Mycophenolate mofetil

Date of use: _____________________________________

Select if the member has history of failure, contraindication, or intolerance to the following topical therapies: (Please provide dates of use

and contraindication to medication, if applicable)

 Medium potency to very-high potency topical corticosteroid [e.g., Elocon (mometasone furoate), Synalar (fluocinolone acetonide),

Lidex (fluocinonide)]

Medication used: _______________________ Date of use: _______________________ Contraindication: _________________

 Topical calcineurin inhibitor** [e.g., Elidel (pimecrolimus), Protopic (tacrolimus)]

Medication used: _______________________ Date of use: _______________________ Contraindication: _________________

 Eucrisa (crisbarole)**

Medication used: _______________________ Date of use: _______________________ Contraindication: _________________

Is the member currently on Dupixent therapy?  Yes  No

Has the patient received a manufacturer supplied sample at no cost in the prescriber’s office, or any form of assistance from the Sanofi

and Regeneron Pharmaceuticals sponsored Dupixent MyWay program (e.g., sample card which can be redeemed at a pharmacy for a

free supply of medication) as a means to establish as a current user of Dupixent)?  Yes  No

Will the member be receiving Dupixent in combination with another biologic medication for the treatment of atopic dermatitis [e.g., Xolair

(omalizumab), Rituxan (rituximab), Enbrel (etanercept), Remicade/Inflectra (infliximab)]?**  Yes  No

Select the prescriber’s specialty:

 Allergist

 Dermatologist

 Immunologist

______________________________________________________________________________________________________________

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider

named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose

PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information

in this document is against the law. If you are not the intended recipient, please notify the sender immediately.

Office use only: Dupixent_UHCE&I_2017Aug-W