Prior Authorization Form Antihemophilia

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Send To:  AcariaHealth
 Specialty Pharmacy Provider:________________
Prior Authorization Form
Phone:
800-218-7453
x22080
Antihemophilia
Fax: 866-683-5631
Date: ____________________ Date Medication Required:_______________________
Patient Name: ___________________________________________________
Physician Name: _____________________________________________
Address: _______________________________________________________
State Lic #____________________ DEA # ________________________
City: ________________________________State: _______Zip:____________
NPI # ________________________ UPIN# __________________________
Home Phone: (___________) _____________ - ________________________
Practice Name/Hospital: _________________________________________
Alt Phone: (___________) _____________ - _________________________
Specialty: ___________________________________________________
Cell Phone: (___________) _____________ - ________________________
Address: ___________________________________________________
Date of Birth: _______/______/______
Sex:  Male Female
City: _________________________ State: ________ Zip: __________
Patient Soc. Sec #: XXX-XX-_____________________
Physician’s Phone: (__________) ____________ - ____________________
Physician’s Fax: (__________) ____________ - ___________________
Allergies:_______________________
County: ____________________
Weight ______
Height: ________
Nurse/Key Office Contact: _______________ Direct Ext: ________________
lbs kg
INSURANCE INFORMATION (Please copy and attach the front and back of insurance and prescription drug card)
Prescription Card:
Name of Insurer: ____________________________
ID#: ______________________
BIN: ___________ PCN: ___________
Group: _______________
Primary Insurance:
Subscriber: ________________________________
ID#: ______________________
Name of Insurer: __________________
Tel #: _______________
Secondary Insurance:
Subscriber: ________________________________
ID#: ______________________
Name of Insurer: __________________
Tel #: _______________
DIAGNOSIS (Required)
 Factor VII deficiency
von Willebrand disease (vWD)
Acquired hemophilia
 Acquired inhibitors to Factor VIII or Factor XI or XII
 Hemophilia with inhibitors
Hemophilia A
Hemophilia B
 Other: _________________
What is the ICD 9 / ICD 10 code? _______________
PATIENT EVALUATION
1.
Is the prescription ordered by or under consultation of a hematologist? Yes No
2.
Has the patient received hepatitis A vaccine?  Yes  No
3.
Has the patient received hepatitis B vaccine?  Yes  No
4.
If at risk, will the patient be monitored for signs and symptoms of thrombosis? Yes  No
5.
Has the patient demonstrated a hypersensitivity to Factor or any of its components (e.g., mouse, hamster, bovine proteins)?  Yes  No
6.
Provide most recent assay level attached to the prior authorization request: Date________ Assay Type ____________ Level______________
Complete the appropriate Section and Group below as applicable to the patient’s prescribed therapy and diagnosis (Sections A-E)
SECTION A: NovoSeven or NovoSeven RT
Group 1: Diagnosis Factor VII deficiency
7.
Will the NovoSeven product be used for prevention or control of bleeding episodes?  Yes  No
Group 2: Hemophilia with inhibitors
8.
What is Bethesda titer (BU) level? __________________BU
9.
Has the patient received prior treatment with Factor VIII?  Yes  No
10.
Has the patient had an inadequate response to Factor VIII dose increases of 20 units/Kg/BU?  Yes  No
SECTION B: Feiba VH or Feiba NF or Autoplex T
11.
Does the patient have inhibitors?  Yes  No
12.
Does the patient have significant signs of disseminated intravascular coagulation (DIC)?  Yes  No
13.
If Feiba,, will Feiba be administered at a high dose (e.g. 100 units/kg as a single dose or 200 units/kg as a daily dose)?  Yes  No *If No, Skip to #15
14.
If Feiba, will the high dose be given only as long as necessary to stop the bleeding?  Yes  No
15.
Document Bethesda titer (BU): __________________BU
16.
Does the patient have other thrombotic risk factors?  Yes  No
SECTION C: Advate, Alphanate, Helixate FS, Hemofil-M, Humate-P, Koate-DVI, Kogenate FS, Monarc-M, Monoclate-P, Recombinate, Refacto, Wilate, Xyntha
17.
Has the patient tried and failed desmopressin?  Yes  No *If No, Skip to # 20
Please continue to second page

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