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

Botulinum Toxins – Medical Necessity Request

**Complete pages 1 and 2 for New (Initial) requests **

General Information

How many units are being prescribed? ______________ What parts of the body will the med be injected into? _____________________

Has the member received another botulinum toxin within the past 4 months? Yes or No

Contraindication Information

For ALL requests:

Does the member have an infection at known injection site? Yes or No

For Botox requests:

Does the member have a hypersensitivity to any botulinum toxin product? Yes or No

For Dysport requests:

Does the member have an allergy to cow's milk protein? Yes or No

Does the member have a hypersensitivity to any botulinum toxin product? Yes or No

For Myobloc requests:

Does the member have a hypersensitivity to any botulinum toxin product? Yes or No

For Xeomin requests:

- Does the member have hypersensitivity to the active substance botulinum neurotoxin type A? Yes or No

Diagnosis Information (please select diagnosis and provide requested information below the diagnosis):

□ Cervical Dystonia/Spasmodic Toritcollis □ Upper limb spasticity

□ Lower limb spasticity

□ Hemifacial or facial spasm

□ Strabismus

□ Blepharospasm

□ Dysphagia

□ Focal and segmental limb dystonia or spasm

□ Primary Axillary Hyperhidrosis

- Is the condition severe? Yes or No

- Is the condition inadequately managed with a topical agent containing aluminum chloride (e.g., Drysol, Xerac and/or Hypercare

20%)? Yes or No

- Does the member have medical complications due to the condition? Yes or No.

* If Yes, please describe: ________________________________________________________________________

- Doe the member have a significant impact to activities of daily living due to the condition? Yes or No

* If Yes, please describe: ________________________________________________________________________

□ Chronic Migraine

- Is the member managed by a Neurologist? Yes or No

- Does the member have a history of experiencing headaches on 15 or more days per month with headaches lasting at least four

hours a day? Yes or No

- What other medications has the member tried for prevention of migraines? ______________________________________

□ Achalasia

- Is the member symptomatic? Yes or No

- Does the member have a concomitant illness? Yes or No

- Is the member at high-risk for complications, such as esophageal reflux or perforation? Yes or No

- Has the member responded to prior myotomy? Yes or No

- Has the member had esophageal perforation associated with pneumatic dilatation? Yes or No

- Does the member have epinephrenic diverticulum? Yes or No

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. 03/16

HNJH Fax #: 888-567-0681

Page

Medical Necessity Request Form

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