Medical Necessity Request Form printable pdf download

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________

Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________

Horizon NJ Health

Biological Response Modifier (BRM), Xeljanz, Xeljanz XR and Otezla – Medical Necessity Request

(Enbrel, Humira, Remicade, Orencia, Kineret, Cimzia, Simponi, Stelara, Actemra, Ilaris, Entyvio, Tysabri, Cosentyx)

**Complete pages 1 and 2 only for New/Initial requests**

General Questions:

What is the diagnosis? _____________________________________________________________________

What is the severity of the disease? _________________________________________

Is the disease active? Yes or No

Is the disease chronic? Yes or No

Does the member have poor prognosis? Yes or No

Is the disease is fistulizing, if applicable? Yes or No

Does the member have any other condition associated with the diagnosis?

______________________________________________________________________________________________

Is the disease refractory, if applicable? Yes or No

What other medications/treatments has the member received in the past for this diagnosis?

________________________________________________________________________________________________________

10. Does the member have any contraindications to any medications such as methotrexate, glucocorticoid (steroid) injections, or

aminosalicylates (drugs such as mesalamine)? Yes or No

- If so, please list the name of the drug. __________________________

11. Why were the previous medications discontinued, if applicable?

________________________________________________________________________________________________________

12. Will the member be taking any other medications concurrently with this medication? Yes or No

- If yes, please list the names of the medications:

____________________________________________________________

________________________________________________________________________________________________________

13. What is the member’s weight? ___________________________ lbs or kg

14. What specialty is managing the member? ___________________________________________

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 3

Rev. 3/16

HNJH Fax #: 888-567-0681

Page

Medical Necessity Request Form