Medical Necessity Request Form (Page 3 of 3) in pdf

Medical Necessity Request Form Page 3

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

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

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

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

**Complete page 3 only for Subsequent/Renewal requests**

1. What is the diagnosis? ______________________________________________

2. What specialty is managing the member ? ___________________________________________

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

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

___________________________________________

4. Is the member concurrently receiving this medication with another Biological Response Modifier (BRM),

Tofacitinib (Xeljanz), or Apremilast (Otezla)? Yes or No

- If yes, Please give the drug name and the reason for receiving more than one BRM, Xeljanz or

Otezla:

_______________________________________________________________________________

5. For Xeljanz or Otezla requests: Will the member also be taking a biologic Disease Modifying Antirheumatic

Drug (DMARD) or potent immunosuppressant (e.g., azathioprine, tacrolimus, cyclosporine)?

Yes or

Physician office's signature*_________________________________ Print Name________________________________

*Form must be completed and signed by physician or licensed representative from the physician’s office

3 of 3

Rev. 3/16

HNJH Fax #: 888-567-0681

Page

Medical Necessity Request Form Page 3