Omalizumab (Ige) Blocker Therapy Prior Authorization Form printable pdf download

NEBRASKA MEDICAID & LONG-TERM CARE

Omalizumab (IgE) Blocker Therapy Prior Authorization Form

Patient’s: Name_________________________________________________________________________

Medicaid ID: _________________________________ Patient’s date of birth: ______________________

Ordering Physician (please print) ____________________________________Specialty ______________

Physician’s Address _____________________________________________________________________

Physician’s Phone____________________________ Physician’s Fax Number ______________________

Please indicate: _____ Initial request or ______ Subsequent request Asthma _______ or Chronic Idiopathic Urticaria ______

ASTHMA:

The patient’s submitted medical record documents indicate that all of the following criteria are met: The patient…

1. Is age 12 or older; and

2. Has had moderate persistent or severe persistent asthma for at least 1 year (X all that apply); and

Severe Persistent:

Moderate Persistent:

___ Continual symptoms; OR

___Daily symptoms (e.g. coughing, wheezing, dyspnea); OR

___Extremely limited physical activity; OR

___Exacerbation affects activity; OR

___Nighttime symptoms frequent; OR

___Nighttime symptoms > 1 time a week

___Daily use of inhaled short acting beta 2-agonist; OR

___FEV1 or PEF < 60% predicted; OR

___PEF variability > 60% but < 80% predicted; OR

___FEV1/FVC is reduced greater than 5%

___FEV1 or FVC is reduced greater than 5%

_____ 3. Has evidence of specific allergic sensitivity, i.e, a positive skin test or in vitro reactivity to a perennial aeroallergen;

TEST RESULT___________________________________________Date___________; and

_____ 4. Has an IgE level of ≥ 30 IU/ml and ≤ 700; LEVEL________________________Date___________; and

_____ 5. Is inadequately controlled for 6 months despite use of standard therapies (circle one that applies):

a. combination of medium dose inhaled corticosteroid and a long-acting beta2 agonist inhaler; or

b. combination of medium dose inhaled corticosteroid and a leukotriene inhibitor; and

_____ 6. Is also being treated with one of the following rescue medications due to inadequate control (

circle one that applies

a. Frequent (2 or more episodes/week) use of a short acting beta2 agonist; or

b. Use of high dose inhaled corticosteroids to maintain adequate control; or

c. Frequent (4 or more per year) short courses of systemic corticosteroids (not oral steroid dependent) to maintain

adequate control; and

_____ 7. Has been compliant with medication usage, peak flow monitoring, regular physician follow-up, and avoidance of

triggering allergens as much as possible; and

_____ 8. Evaluation and medical records of the asthma specialist who is prescribing IgE blocker therapy are attached.

Any additional physician comments: __________________________________________________________________________

________________________________________________________________________________________________________

CHRONIC IDIOPATHIC URTICARIA (CIU):

The patient’s submitted medical record documents indicate that all of the following criteria are met: The patient…

_____ 1. Is age 12 or older; and

_____ 2. Has had moderate persistent or severe chronic idiopathic urticaria for at least 1 year; and

_____ 3. Prescribed by an Allergist, Immunologist, or Dermatologist (circle which applies); and

_____ 4. Documented failure of, or contraindication to, antihistamine, leukotriene inhibitor and immunosuppressive therapies; and

_____ 5. Evaluation and medical records of the specialist who is prescribing IgE blocker therapy are attached to include evidence

of an evaluation that excludes other medical diagnoses associated with chronic idiopathic urticaria.

Any additional physician comments: __________________________________________________________________________

________________________________________________________________________________________________________

Ordering Physician’s Signature ___________________________________________________ Date ____________________

Submit this form and medical records to Nebraska Medicaid Physicians Program Specialist by:

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

Omalizumab (Ige) Blocker Therapy Prior Authorization Form

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