Tysabri (Natalizumab) Prior Authorization Form printable pdf download

NEBRASKA MEDICAID & LONG-TERM CARE

TYSABRI (Natalizumab) Prior Authorization Form

Patient’ Name_________________________________________________________________________

Medicaid ID _________________________________ Patient’s date of birth ______________________

Physician (please print) _____________________________________Specialty √ ____Neurology ____ GI

TOUCH program enrolled? √ ___ yes ____no

Physician’s Address _____________________________________________________________________

Physician’s Phone (

) ______________________ Physician’s Fax Number ( )_____________________

TYSABRI is covered for Multiple Sclerosis and Crohn’s disease. Prescribing physician and patient must be

enrolled with TOUCH prescribing program. The provider has the responsibility to verify a client’s

eligibility and other limitations that apply to a specific client.

√ ____ Initial dose: Documentation to include but not limited to:

1. Supporting clinical documentation for medical necessity including diagnosis and severity,

2. Previous therapies tried and patient response to each (list medications).

3. Copy of TOUCH program authorization for the client.

√ ____ Subsequent request: Documentation to include but not limited to:

1. Supporting clinical documentation for medical necessity including last progress note indicating

patient response to therapy and MRI results, if done.

2. Copy of TOUCH program authorization form for client.

Any additional physician comments:

Ordering Physician’s Signature ___________________________________________ Date ___________

Submit this form and medical records to Nebraska Medicaid Physician’s Program Specialist by:

FAX: (402) 471-9092; EFAX to (402) 472-1104; or Mail at P.O. Box 95026, Lincoln, NE 68509

DO NOT WRITE BELOW THIS LINE-MEDICAID USE ONLY:

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_____ Approval for Ongoing Therapy for 6 months from _______________ to _________________

_____Denied/ Rationale _________________________________________________________________

_____Unable to determine ________________________________________________________________

Signature _______________________________________________________Date ___________________

Program Specialist

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Tysabri (Natalizumab) Prior Authorization Form