Form Dmas-P220 - Virginia Medicaid Request For Service Authorization - Farydak

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VIRGINIA MEDICAID
REQUEST FOR
SERVICE AUTHORIZATION
DUR Medication
COMMONWEALTH of VIRGINIA
®
FARYDAK
(PANOBINSTAT)
Department of Medical Assistance Services
Requests for service authorization (SA) must include patient name, Medicaid ID#, and drug name. Appropriate clinical information to support the request on the basis of
medical necessity must be submitted. Please include all requested information; incomplete forms will delay the SA process. SUBMISSION OF DOCUMENTATION
DOES NOT GUARANTEE COVERAGE BY THE DEPARTMENT OF MEDICAL ASSISTANCE SERVICES AND FINAL COVERAGE DECISIONS MAY
BE AFFECTED BY SPECIFIC MEDICAID LIMITATIONS.
FAXED TO 800-932-6651.
The completed form may be
Requests may be phoned to 800-932-6648.
Requests may be mailed to: Magellan Medicaid Administration / 11013 W. Broad Street, Suite 500/ Glen Allen, VA 23060 / ATTN: MAP
Today’s Date: ___ ___/___ ___/___ ___ ___ ___
Requested Start Date: ___ ___/___ ___/___ ___ ___ ___
PATIENT INFORMATION
Name: (Last, First) ____________________________________ Medicaid ID#: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ __
Date of Birth: ___ ___/___ ___/___ ___ ___ ___
Gender:
Male
Female
DRUG INFORMATION
Drug Name/ Form: ______________________________________________
Strength: _______________________________
Dosing Frequency: ______________________________________________
Length of Therapy: _______________________
Quantity per day: ________________________________________________
DIAGNOSIS AND MEDICAL INFORMATION – Please Answer All Questions To Facilitate Processing
®
FARYDAK
- to receive a SIX (6) month approval for this drug, please complete the questions below.
Does the patient meet the following criteria?
•
Diagnosis of relapsed multiple myeloma.
Yes
No
•
Patient has received at least 2 prior regimens with bortezomib (Velcade) and an immunomodulatory derivative
(thalidomide (Thalomid), lenalidomide (Revlimid) or pomalidomide (Pomalyst)?
Yes
No
•
State regimen and dates of therapy:
Drug or Treatment Protocol Name: _______________________________Date received____________________________
Drug or Treatment Protocol Name: _______________________________Date received____________________________
Drug or Treatment Protocol Name: _______________________________Date received____________________________
•
Patient is concurrently receiving treatment with bortezomib (Velcade) and dexamethasone?
Yes
No
•
Is the medication being prescribed by an oncologist or hematologist?
Yes
No
•
Is the patient 18 years of age or older?
Yes
No
Medical necessity: Provide clinical evidence that support the use of the requested medication.
PRESCRIBER INFORMATION
Name/Specialty (print):_______________________________________________
NPI Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Phone Number: (___ ___ ___) ___ ___ ___-___ ___ ___ ___
Fax Number: ( ___ ___ ___) ___ ___ ___-___ ___ ___ ___
Signature of Prescribing Provider: ______________________________________________
PLEASE INCLUDE ALL REQUESTED INFORMATION
INCOMPLETE FORMS WILL DELAY THE SERVICE AUTHORIZATION PROCESS
FAX TO 800-932-6651
SERVICE AUTHORIZATION CRITERIA IS SUBJECT TO CHANGE AND THUS DRUG COVERAGE
DMAS-P220
05/2015

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