Xolair Prior Authorization - Healthyct

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Catamaran Prior Authorization Department
Phone:
800-626-0072
Fax:
866-511-2202
Prescriber Information
Last Name
First Name
DEA / NPI
Specialty
Phone
Fax
-
-
-
-
Member Information
Last Name
First Name
Member ID Number
DOB
Medication Information:
Drug Name and Strength:
Quantity:
Diagnosis:
Dosing:
For injectable medications that are being purchased and administered by the physician’s office, fax this
request to HealthyCT at (855) 817-5696 to obtain a Prior Authorization through medical coverage. For
any questions, please call HealthyCT at (855) 458-4928.
You must answer ALL of the following questions
Is the medication being purchased by the member at a specialty or retail pharmacy?
Y N
If Yes: Proceed filling out the fax form and submit via fax to Catamaran Prior Authorization Dept.
If No: Proceed filling out the fax form and submit via fax to HealthyCT at (855) 817-5696 to obtain a
Prior Authorization through medical coverage.
Xolair Prior Authorization
Initial Therapy
You must answer ALL of the following questions
1.
Is the patient 12 years of age or older?
Y N
What is the patient’s diagnosis? Please CIrcle
2.
• Moderate to severe persistent allergic asthma
• Chronic idiopathic urticaria (CIU)
• Other: _____________________________________________________________________
3.
Does the patient have evidence of specific allergic sensitivity confirmed by positive skin test (i.e.
Y N
prick/puncture test) or blood test (i.e. radioallergosorbent test) for a specific immunoglobulin E
(IgE) or in vitro reactivity to a perennial aeroallergen?
4.
Does the patient have pretreatment serum IgE levels that are at least 30 but less than or equal to
Y N
700 IU/mL?
Are the patient’s symptoms not adequately controlled with high-dose inhaled corticosteroid (ICS)
5.
Y N
plus long-acting beta2-agonist (LABA) for at least 3 months?
6.
Has the patient been adherent within a 12 month period, and is the patient currently adherent, with
Y N
asthma therapy?
7.
Was the medication prescribed by or in consultation with an allergist, immunologist, or
Y N
pulmonologist?
Page 1 of 3
7/2/2014

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