Omalizumab (Xolair) - 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
Omalizumab (Xolair) – Medical Necessity Request
**Complete page 1 for New/Initial requests**
What is the prescriber's specialty? □ Allergy □ Pulmonology □ Dermatology
□ Other: ___________________________
1.
2.
Is the medication being administered in the physician's office? Yes or No
3.
What is the diagnosis?
□ Urticaria
a) Is the urticaria chronic (continuously or intermittently present for at least 6 weeks)? Yes or No
b) Is the urticaria idiopathic (of unknown cause)? Yes or No
c) Has member tried H1-antihistamine therapy? Yes Or No
- If No, can the member try H1-antihistamine (e.g. OTC Loratadine, OTC cetirizine)? Yes or No
- If No, Please provide clinical reason ___________________________________________________
d)
Has member tried H2-antihistamine therapy? Yes or No
- If No, can the member try H2-antihistamine (e.g. Ranitidine, Famotidine, Nizatidine)? Yes or No
- If No, Please provide clinical reason ___________________________________________________
e) Has member tried a leukotriene modifier (e.g. montelukast, accolate, zyflo CR), hydroxyzine or doxepin? Yes or No
- If No, Can member try a leukotriene modifier (Montelukast), hydroxyzine or doxepin? Yes or No
- If No, Please provide clinical reason _________________________________________________
□ Allergic Asthma (go to Question #4)
□ Asthma and Allergies (go to Question #4)
□ Asthma (Please answer the following and then go to Question #4)
- Is the asthma allergic? Yes or No
- If not, does the member also have allergies? Yes or No
□ Allergies (Please answer the following and then go to Question #4)
- Does the member also have asthma? Yes or No
□ Other: _____________________
4.
For Allergic Asthma, Allergies, Asthma and Asthma and Allergies
A. Please indicate the severity of the asthma:
□ mild
□ moderate
□ severe
B. Has the member received Xolair within the past year? Yes or No
C. What is the member's current weight? __________lbs
Date Taken: ____________
__________ kg
D. What was the member's pre-treatment IgE level (IU/ml)? __________________
E. What is the current IgE level (IU/ml)? ___________ Date Taken: ______________
F. Has the member had a positive skin test or in vitro reactivity to a perennial aeroallergen (e.g. prick/puncture test,
intracutaneous test, RAST)? Yes or No
G. Has the member been using a high-dose inhaled corticosteroid together with a long-acting beta agonist for the past 3
months? (e.g, Advair, Dulera, Symbicort, etc.) Yes or No
-
If yes, is the member symptomatic or inadequately controlled? Yes or No
H. Does the member currently smoke? Yes or No
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
1 of 2
Rev. 03/16
HNJH Fax #: 888-567-0681
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