Medical Necessity Request Form
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1Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Antiretroviral Medications – Medical Necessity Request
Diagnosis Information (please indicate diagnosis and answer related questions):
□ HIV
□ AIDS - For a diagnosis of AIDS, what opportunistic infection or CD4 count confirms the diagnosis of AIDS?
________________________________________________________________________________________________________
□ Pre-Exposure Prophylaxis (PrEP)
1. Which of the following criteria does the member meet?
□ Sexually-active MSM (men who have sex with men)
□ Heterosexually active man or woman
□ Bisexual man
□ Injection drug user
□ NONE
2. Will this medication be part of a comprehensive prevention strategy? Yes or No
3. Has the member recently had an HIV-1 test? *Note: Please fax the lab results for the HIV-1 test from within past 90 days.
□ Yes
Result: □ Positive □ Negative
Date taken: ______________
□ No: Please provide the clinical reason why an HIV-1 test has not been performed.
_________________________________________________________________________________________________
4. Will the member be screened for HIV-1 at least once every 3 months while taking this medication?
□ Yes
□ No: Please provide the reason why the member will not be screened for HIV-1.
_________________________________________________________________________________________________
5. What is the member's most recent creatinine clearance level in ml/min? ___________________________________________
6. Will the member be tested for normal renal function at least every 6 months? Yes or No
□ Infant Antiretroviral Prophylaxis
□ Post-Exposure Prophylaxis (PEP) [example: needle stick, sexual assault]
1. Will HIV-1 tests be performed at baseline, 4-6 weeks, 3 months, and 6 months following exposure?
□ Yes
□ No: Please provide the reason why HIV-1 tests will not be performed at the recommended time points.
________________________________________________________________________________________________
2. Will the total duration of therapy be more than 28 days?
□ Yes: Please provide the clinical reason for giving treatment beyond 28 days.
________________________________________________________________________________________________
□ No
□ Chronic Hepatitis B
1. Has the member’s HBsAg (Hepatitis B surface antigen) been positive for more than 6 months? Yes or No
□ Other: __________________________________________________________________________________________
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
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Rev. 03/16
HNJH Fax #: 888-567-0681
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