Ambetter Prior Authorization Form - Amevive

Send To:

AcariaHealth

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Specialty Pharmacy Provider:________________

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Date: ___________ Date Medication Required:____________

Ship to:

Physician

Patient’s Home

Other __________

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Prior Authorization Form

Amevive

Patient Name: ____________________________________________________

Physician Name: _______________________________________________

Address: ________________________________________________________

State Lic #______________________ DEA # ________________________

City: _________________________________State: _______Zip:____________

NPI # _________________________ Specialty: _____________________

Home Phone: (___________) _____________ - _________________________

Practice Name/Hospital: _________________________________________

Work Phone: (___________) _____________ - _________________________

Address: _____________________________________________________

Cell Phone: (___________) _____________ - _________________________

City: __________________________ State: ________ Zip: ____________

Patient Soc. Sec #: __________________ Allergies:_______________________

Physician’s Ph: (__________) ____________ - ______________________

Date of Birth: ___/___/___ Sex:

Male

Female

Weight ______

Physician’s Fax: (__________) ____________ - _____________________

lbs

kg

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Height: _______ BSA: ________ m²

See attached demographic sheet

Nurse/Key Office Contact: ________________________________________

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INSURANCE INFORMATION (Complete or Attach Copies of cards)

Primary Insurance:__________________

Secondary Insurance:________________

Rx Card (PBM):_____________________

Cardholder First Name: ______________

City:______________State:___________

City:______________State:___________

PBM BIN: ________________________

Last Name: _______________________

Plan #: ___________________________

Plan #: ___________________________

City:______________State:___________

Employer: ________________________

Group #: _________________________

Group #: _________________________

Group #: _________________________

ID #: ____________________________

Phone: (______) ________-__________

Phone: (______) ________-__________

Phone: (______) ________-__________

Group #: _________________________

DIAGNOSIS (Required)

Psoriasis (adult or child)

Other: __________

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What is the ICD9 / ICD10 code? ________________________

PATIENT EVALUATION

1. Is the patient HIV positive?

Yes

No

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2. Document BASELINE CD4 count: _______________ cells/ μL

3. Will CD4 count be monitored every 2 weeks throughout the course?

Yes

No

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4. Does the patient have an active infection (chronic or localized) or malignant disease?

Yes

No

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5. Will Amevive be used in combination with another biologic or immunosuppressant?

Yes

No

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6. What is the medical specialty of the prescribing physician?

Dermatologist

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Other ____________________________

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7. What is the current percentage of body surface area (BSA) affected? _______________ %

8. Does the patient’s psoriasis involve palms, soles, face and neck or genitalia?

Yes

No

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9. Is the patient currently on the prescribed biologic? Yes No *If yes, skip to #14

10. Has the patient had a trial of all three of the following therapies for 3 consecutive months?

Yes

No *If yes, indicate below

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Topical treatment (e.g., calcipotriene, tazarotene, coal tar preparations, anthralin, medium to high potency corticosteroids)

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Phototherapy

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One systemic therapy (e.g., methotrexate, thioguanine, cyclosporine, acitretin)

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11. Has the patient had an inadequate response to such therapies?

Yes

No

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12. Was the patient adherent to each prescribed therapies?

Yes

No

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13. Document last trial of conventional therapy unless contraindicated _________________________________________________________________

Only answer the below questions if patient is currently receiving Amevive therapy

14. Has the patient received 2 courses of Amevive therapy?

Yes No

15. How many TOTAL courses of Amevive therapy has patient received? _______________________________________________________

16. Document the patient’s CURRENT CD4 count _______________ cells/μL

17. Will Amevive dose be withheld if CD4+ counts fall below 250 cells/uL?

Yes

No

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18. Will Amevive be discontinued if CD4+ counts remain below 250 cells/uL for one month?

Yes

No

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19. Document date of last Amevive injection _____________________________________________________________________

MEDICATION

STRENGTH

DIRECTIONS

QUANTITY

REFILLS

Amevive

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Physician’s Signature: ____________________________________

Date____/_____/____

 DAW (Dispense as Written)

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