Prior Authorization Form Page 2

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US Family Health Plan Prior Authorization Request Form for
dabrafenib (Tafinlar)
To be completed and signed by the prescriber. To be used only for prescriptions which are to be filled through the Department of Defense (DoD)
US Family Health Plan pharmacy program (USFHP).
• The provider may call:
or the completed form may be faxed to:
• The patient may attach the completed form to the prescription and mail
it to: ATTN: Pharmacy, 77 Warren St, Brighton, MA 02135
Prior authorization criteria and a copy of this form are available at: .
This prior authorization has no expiration date.
Step
Please complete patient and physician information (please print):
1
Patient Name:
Physician Name:
Address:
Address:
Sponsor ID #
Phone #:
Date of Birth:
Secure Fax #:
Step
Please complete the clinical assessment:
2
 Yes
 No
1. Does the patient have a diagnosis of unresectable or
metastatic melanoma?
Proceed to question 2
STOP
Coverage not approved
 Yes
 No
2. Will Tafinlar be used as a single agent for the treatment
of this diagnosis?
Proceed to question 3
to question
SKIP
4
 Yes
 No
3. Does the patient have a BRAF V600E mutation as
detected by an FDA-approved test?
to question
SKIP
6
STOP
Coverage not approved
 Yes
 No
4. Will Tafinlar be used in combination with Mekinist
(trametinib)?
Proceed to question 5
STOP
Coverage not approved
 Yes
 No
5. Does the patient have a BRAF V600E or V600K
mutation?
Proceed to question 6
STOP
Coverage not approved
 Yes
 No
6. Does the patient have a wild-type BRAF melanoma?
Coverage not approved
Sign and date below
Step
I certify the above is true to the best of my knowledge. Please sign and date:
3
Prescriber Signature
Date
[19 November 2014]

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