Xolair (Omalizumab) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
®
(
)
Xolair
omalizumab
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: __________________________________
Prescribing Physician: ____________________________
Patient ID #:
__________________________________
Physician Address:
_____________________________
Patient DOB: __________________________________
Physician Phone #:
_____________________________
Date of Rx:
__________________________________
Physician Fax #:
_____________________________
Patient Phone #: _______________________________
Physician Specialty:
____________________________
Patient Email Address: ___________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION REQUESTED
4. DOSAGE REQUESTED SQ
5. ADMINISTRATION FREQUENCY
□
□
Every 2 weeks
Every 4 weeks
□
□
Xolair (omalizumab)
150 mg
Other _______
□
Other _________________________
6. DIAGNOSIS: ______________________________________________________________________________
CHECK ALL BOXES THAT APPLY
7.
APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
□
□
Yes
No
Patient is 12 years of age or older
□
□
Yes
No
Patient has a diagnosis of Moderate Persistent to Severe Persistent asthma If Yes:
□
□
Yes
No
Patient has an forced expiratory volume in one second (FEV1) less than 80%
predicted
□
□
Yes
No
Patient has a positive skin test or in vitro reactivity to a perennial aeroallergen
□
□
Yes
No
Patient has an serum Immunoglobulin E (IgE) level that is greater than or equal
to 30 IU/ml
□
□
Yes
No
Patient has symptoms that are inadequately controlled after a minimum of 3
months of combination controller therapy (medium to high dose inhaled
corticosteroids plus long acting beta-2 agonists or leukotriene receptor
antagonists), or cannot tolerate these medications
□
□
Yes
No
Xolair (omalizumab) is being used for the treatment of chronic idiopathic urticaria (CIU) as fourth-line
therapy If Yes:
□
□
Yes
No
The patient's symptoms of CIU are refractory to prior treatment with antihistamines
at maximal FDA-approved dosages, according to the step-care protocols for first-,
second-, and third-lines of therapy (which includes H
antihistamines, H
1
2
antihistamines and leukotriene receptor antagonists)
□
□
Yes
No
The request is for continued therapy If Yes:
□
□
Yes
No
Treatment with Xolair (omalizumab) resulted in clinical improvement as
documented by ONE OR MORE of the following:
□
Decreased utilization of rescue medications
□
Decreased frequency of exacerbations (defined as worsening of asthma that requires increase in
inhaled corticosteroid dose or treatment with systemic corticosteroids)
□
Increase in percent predicted FEV1 from pretreatment baseline
□
Reduction in reported asthma- related symptoms, such as, but not limited to, wheezing,
shortness of breath, coughing, fatigue, sleep disturbance, or asthmatic symptoms upon
awakening
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CONTINUED ON PAGE 2
Xolair NTL PAB Fax Form 02.02.15.doc
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