Prior Authorization / Preferred Drug List (Page 2 of 3) in pdf

Prior Authorization / Preferred Drug List Page 2

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR ANTIEMETICS, CANNABINOIDS

Page 2 of 3

F-00194 (07/13)

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).



20. Is the member currently taking Marinol

Yes

If yes, list the date Marinol

was started.

List the daily dose of Marinol

List the member’s weight (in pounds) prior to starting Marinol

treatment.

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

22. Has the member experienced an unsatisfactory therapeutic response or a clinically



significant adverse drug reaction with ondansetron?

Yes

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

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

If yes, list the medical condition(s) and describe how the condition(s) prevents the member from using ondansetron in the space

provided.

Continued

Prior Authorization / Preferred Drug List Page 2