Xolair Prior Authorization - Healthyct Page 2
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3Catamaran Prior Authorization Department
Phone:
800-626-0072
Fax:
866-511-2202
8.
Does the patient have a history of itching and hives for at least 4 consecutive weeks despite
Y N
optimal treatment with a non-sedating H1 antihistamine?
9.
Has the patient tried and had an inadequate response, intolerance, or contraindication to one other
Y N
listed therapy? Please Circle
• Montelukast
• Oral corticosteroid
10.
Will the patient use Xolair concurrently with H1 antihistamine therapy?
Y N
11.
Is the medication being prescribed by or in consultation with an allergist, immunologist, or
Y N
dermatologist?
Repeat 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.
Has the patient experienced an objective response to therapy, defined as one or more of the
Y N
following? Please Circle
• Reduction in number of asthma exacerbations from baseline (i.e. asthma exacerbation requiring
treatment with systemic corticosteroids or doubling of ICS dose from baseline)
• Improvement in forced expiratory volume in 1 second (FEV1) from baseline
• Decreased use of rescue medications from baseline
Has the patient’s disease status been re-evaluated since last authorization to confirm the patient’s
4.
Y N
condition warrants continued treatment?
5.
Has the patient experienced an objective response to therapy, defined as one or both of the
Y N
following? Please Circle
• Reduction in itching severity from baseline
• Reduction in the number of hives from baseline
Comments:
Information given on this form is accurate as of this date.
Prescriber or Authorized Signature
Date
Authorized Medical Staff – Name/Title
Attention Healthcare Provider: If you would like to discuss this request with a medical professional, please
contact the Prior Authorization Department at 800-626-0072.
I understand that Catamaran’s use or disclosure of individually identifiable health information, whether furnished
by me or obtained by another source such as medical providers, shall be in accordance with federal privacy
regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996).
Page 2 of 3
7/2/2014
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