Medical Necessity Request Form

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Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Lubiprostone (Amitiza) and Linaclotide (Linzess) – Medical Necessity Request
Request for Amitiza
Contraindication Information:
1.
Does member have known or suspected mechanical gastrointestinal (GI) obstruction? Yes or No
Diagnosis Information (please indicate diagnosis and answer related questions):
Opioid Induced constipation
-
Does member have chronic pain associated with Cancer? Yes or No
-
What opioid therapy is the member currently receiving and when was it last received? [NOTE: Examples of
opioids include: oxycodone, hydrocodone, morphine, OxyContin, MS Contin, Kadian, Duragesic/Fentanyl]
__________________________________________________________________________________________
________________________________________________________________________
-
Is the request for 24mcg twice daily? Yes or No
- If No, Can the dose be changed to 24mcg twice daily? Yes or No
- If No, What is the clinical reason it cannot be changed?
_________________________________________________________________________________
Chronic Idiopathic Constipation
-
Is the request for 24mcg twice daily? Yes or No
- If No, Can the dose be changed to 24mcg twice daily? Yes or No
- If No, What is the clinical reason it cannot be changed?
_________________________________________________________________________________
Irritable Bowel Syndrome
Is the member’s IBS constipation predominant? Yes or No
-
-
Is the request for 8mcg twice daily? Yes or No
- If No, Can the dose be changed to 8mcg twice daily? Yes or No
- If No, What is the clinical reason it cannot be changed?
_____________________________________________________________________________________
□
Constipation
-
Is the constipation Opioid-induced? Yes or No
- If yes, does member have chronic pain associated with Cancer? Yes or No
-
Have other causes of constipation been ruled out? Yes or No
-
Does the member have acute or chronic constipation? Acute or Chronic
-
Is the request for 24mcg twice daily? Yes or No
- If No, Can the dose be changed to 24mcg twice daily? Yes or No
- If No, What is the clinical reason it cannot be changed?
_________________________________________________________________________________
□ Other: _____________________________________________
(Continued on p. 2)
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
1 of 2
Rev. 03/16
HNJH Fax #: 888-567-0681
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