Omalizumab (Xolair) - Medical Necessity Request Form (Page 2 of 2) in pdf

Omalizumab (Xolair) - Medical Necessity Request Form Page 2

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

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

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

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

**Complete page 2 only for Subsequent/Renewal requests**

What is the prescriber’s specialty? □ Allergy □ Pulmonology

□ Dermatology

□ Other: _______________

Is the medication being administered in the physician's office? Yes or No

What is the diagnosis? (please CHECK the member’s diagnosis AND then answer the additional questions)

Diagnosis

Additional Questions

None

□ Chronic Idiopathic Urticaria

What is the member’s current weight?

__________lbs

Date Taken: _____________

□ Allergic Asthma

__________ kg

□ Allergies and Asthma

What was the member's pre-treatment IgE level (IU/ml)? ___________________

□ Asthma

Has the member responded to therapy by showing clinical improvement and/or

stable asthma control? Yes or No

□ Allergies

Is the member currently smoking? Yes or No

Please provide any additional clinical information pertaining to the request.

□ Other _______________

Physician office's signature*_________________________________ Print Name________________________________

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

2 of 2

Rev. 03/16

HNJH Fax #: 888-567-0681

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Omalizumab (Xolair) - Medical Necessity Request Form Page 2