Hemophilia Medications - 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
Hemophilia Medications – Medical Necessity Request
1. How many units per dose were requested by the prescriber (units prescribed)? ____________________
2. What is the acceptable variance requested by the prescriber? __________________________________
3. How often is this dose to be administered? ________________________________________________
4. Is this a dose increase or the same dose the member has been receiving?
□ Dose Increase
a. When was the dose last received? __________________________________________
b. What were the units per dose requested by the prescriber? _______________________
c. What was the acceptable variance requested by the prescriber? ___________________
d. How often was this dose administered? ______________________________________
e. What was the Assay(s) of the lot number(s) that were dispensed by the pharmacy?
__________________________________________________________________________
□ Same Dose
5. What is the reason for the requested dose?
□ Active hemorrhage (bleed)
□ Mild
□Moderate
□Severe
a. What is the severity of the bleed?
□ Surgical Procedure
a. Is the member having major or minor surgery? □ Major □ Minor
b. Please describe the type of surgical procedure the member will be undergoing.
___________________________________________________________________________
___________________________________________________________________________
□ Development of Inhibitor (antibody to factor)
□ Other: ____________________________________
6. What is the member's current weight?
_____lbs
_____kg
7. What date was the weight taken? ________________
8. What is the NDC of the factor being used by the pharmacy? ___________________________________
9. What is the Assay(s) of the lot number(s) being dispensed by the pharmacy (the shipped dose)?
___________________________________________________________________________________
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
1 of 1
Rev. 03/16
HNJH Fax #: 888-567-0681
Page

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