Dupixent Prior Authorization Request Form (Page 2 of 2) in pdf

Dupixent

Prior Authorization Request Form (Page 2 of 2)

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

Reauthorization:*

If this is a reauthorization request, answer the following questions:

Is the member currently on the requested medication?  Yes  No

Is there documentation the member has had a positive clinical response to Dupixent therapy?  Yes  No

Is the member is 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

Quantity Limit Requests:*

Is this request for 4 syringes once per 365 days to account for loading dose?  Yes  No

Prescriber attestation:

Does the prescriber attest that the information provided is true and accurate to the best of their knowledge and understand that United

Healthcare may perform a routine audit and request the medical information necessary to verify the accuracy of the information

provided?  Yes  No

Prescriber’s signature: ________________________________________________________

Date: ____________________________

*May not apply to all plans

**This product may require prior authorization

Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to

this review?

______________________________________________________________________________________________________________

Please note:

This request may be denied unless all required information is received within established timelines.

This request may be denied unless all required information is received.

For urgent or expedited requests please call 1-800-711-4555.

This form may be used for non-urgent requests and faxed to 1-800-527-0531.

______________________________________________________________________________________________________________

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