PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR ANTIEMETICS, CANNABINOIDS
Page 2 of 3
F-00194 (07/13)
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SECTION III A — CLINICAL INFORMATION FOR MARINOL
FOR HIV- AND AIDS-RELATED WEIGHT LOSS OR CACHEXIA
(Continued)
18. List the details about the member’s current dietary plan, including daily caloric intake.
19. Indicate the member’s normal baseline weight (in pounds).
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20. Is the member currently taking Marinol
?
Yes
No
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If yes, list the date Marinol
was started.
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List the daily dose of Marinol
.
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List the member’s weight (in pounds) prior to starting Marinol
treatment.
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SECTION III B — CLINICAL INFORMATION FOR MARINOL
AND CESAMET FOR CHEMOTHERAPY-RELATED NAUSEA AND
VOMITING
21. Is the member experiencing chemotherapy-related nausea and vomiting?
Yes
No
22. Has the member experienced an unsatisfactory therapeutic response or a clinically
significant adverse drug reaction with ondansetron?
Yes
No
If yes, list the dates ondansetron was taken.
Describe the unsatisfactory therapeutic response or clinically significant adverse drug reaction.
23. Is there a clinically significant drug interaction between another drug(s) the member
is taking and ondansetron?
Yes
No
If yes, list the drug(s) and interaction(s) in the space provided.
24. Does the member have a medical condition(s) that prevents the use of ondansetron?
Yes
No
If yes, list the medical condition(s) and describe how the condition(s) prevents the member from using ondansetron in the space
provided.
Continued