Form Dmas-P197 - Virginia Medicaid Request For Service Authorization Bowel Disorder Medications - Virginia Department Of Medical Assistance Services
ADVERTISEMENT
1VIRGINIA MEDICAID
REQUEST FOR SERVICE
AUTHORIZATION
COMMONWEALTH of VIRGINIA
BOWEL DISORDER MEDICATIONS
Department of Medical Assistance Services
Requests for service authorization (SA) must include patient name, Medicaid ID#, drug name, and appropriate clinical
information to support the request on the basis of medical necessity. 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 the specific Medicaid Limitations.
The completed form may be FAXED TO 800-932-6651. Requests may be phoned to 800-932-6648.
Requests may be mailed to: Magellan Medicaid Administration / 11013 W. Broad St / Glen Allen, VA 23060 / ATTN: MAP
All questions must be answered.
Today’s Date: ___ ___/___ ___/___ ___ ___ ___
Requested Start Date: ___ ___/___ ___/___ ___ ___ ___
PATIENT INFORMATION
Name: (Last, First) ____________________________________________
Medicaid ID#: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Date of Birth: ___ ___/___ ___/___ ___ ___ ___
Gender:
Male
Female
DRUG INFORMATION
®
Preferred Medication (Amitiza
) must be tried and failed 1st
Non-preferred Medications
®
®
TM
Relistor
Viberzi
Linzess® Lotronex® Movantik
Drug Name/ Form: ______________________________________________
Strength: _______________________________
Dosing Frequency: ______________________________________________
Length of Therapy: _______________________
DIAGNOSIS AND MEDICAL INFORMATION
Does the patient have any of the following diagnoses? Please check all that apply.
Idiopathic Chronic Constipation (ICC)
Yes
No
Constipation Predominant Irritable Bowel Syndrome (IBS-C)
Yes
No
Severe Diarrhea Predominant Irritable Bowel Syndrome (IBS-D)
Yes
No
Opioid Induced Constipation in chronic NON-cancer pain (OIC)
Yes
No
Other _________________________________________________________________________________________
Yes
No
1) Amitiza® / Linzess®: Has the patient had a treatment failure on at least TWO of the following classes:
Yes
No
Osmotic Laxatives (i.e. lactulose, polyethylene glycol, sorbitol), Bulk Forming Laxatives (i.e. psyllium, fiber)
Or Stimulant Laxatives (i.e. bisacodyl, senna)?
®
2) Amitiza® /
Movantik
(OIC only): Has the patient had treatment failure on both polyethylene glycol
Yes
No
AND lactulose?
TM
3) Lotronex®/ Viberzi
: Has the patient had a treatment failure on at least THREE of the following classes:
Yes
No
Bulk Forming Laxatives (i.e. psyllium, fiber), Antispasmodic Agents (i.e. dicyclomine, hyoscyamine)
OR Antidiarrheal Agents (i.e. loperamide, diphenoxylate/atropine, codeine)?
List pharmaceutical agents attempted and outcome:
1.
2.
MEDICAL NECESSITY: Provide clinical evidence that the preferred agent(s) will not provide adequate benefit.
PRESCRIBER INFORMATION
Name (print):_____________________________________________
NPI Number: ____________________________________
Phone Number: (___ ___ ___) ___ ___ ___-___ ___ ___ ___
Fax Number: ( ___ ___ ___) ___ ___ ___-___ ___ ___ ___
Prescribing Provider’s Signature: ______________________________________________ Date:_______________________________
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
DMAS-P197
3/2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dma-3066 - Independent Assessment Request For New Admissions - North Carolina Department Of Health And Human Services
Legal
Form 8003 - Request For Additional Information From Tax-exempt Organizations - Department Of The Treasury - Internal Revenue Service
Financial
Related Categories
Parent category: Legal