Nebraska Medicaid Program Request For Prior Authorization Of Payment Amylinomimetic Agents Form

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NEBRASKA MEDICAID PROGRAM REQUEST FOR PRIOR AUTHORIZATION OF PAYMENT
AMYLINOMIMETIC AGENTS
(NOTE: All Amylinomimetic agents approved subsequent to this bulletin shall be subject to these criteria.)
The first PA will be effective for 6 months; thereafter, a new PA must be requested every 12 months.
Brand Name
Generic Name
Symlin®
Pramlintide
PRESCRIBING PROVIDER:
MEDICAID RECIPIENT:
Name: _________________________________
Name: _________________________________
First
Last
First
Last
Phone #: (____)-_________________________
Medicaid #:
/
/
Fax #:
(____)-__________________________
Date of Birth:
NPI # ____________________________________
(NOTE: Patient must be 18 years or older.)
PARTICIPATING PHARMACY:
Name: ________________________________
Request Date: __________________________
Phone #: (____)-________________________
Fax #: (____)-___________________________
Requested Drug Name:
Strength:
Administration Schedule:
AMYLINOMIMETIC AGENT CRITERIA: Client must be 18 years of age or older.
1. Is the patient currently using short-acting (Humalog®,
Yes
No If no, denied.
Novolog®, Apidra®, Humulin® R, Novolin® R, Humulin®
70/30, 50/50, NovoMix® 30) mealtime insulin injections?
2. Has the current mealtime insulin dose been reduced by
Yes
No If no, denied.
50% for initiation of amylinomimetic agent therapy?
3. Is the patient receiving blood glucose testing supplies for
Yes
No If no, denied.
self-monitoring during amylinomimetic agent initiation?
4. Does the patient show documented compliance with current
Yes
No
therapy? (Compliance will be verified utilizing Medicaid
claims data.)
5. Does the patient have a clinical diagnosis of gastroparesis?
Yes
No If yes, denied.
6. Is the patient HgbA1C>9?
Yes
No If yes, denied.
Please attach a copy of patient’s most recent (within
The previous 90 days) HgbA1C lab.
Prescriber Signature: _____________________________________________ Date: ____________________
(With this signature, the prescriber confirms that the information above is accurate and verifiable in patient records.)
Please note: The Department may request chart documentation to verify the above information.
Submit requests to:
Magellan Medicaid Administration, Inc.
Fax: 1-866-759-4115
Tel: 1-800-241-8335
Rev. March 2015

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