Malathion (Ovide) - 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
Malathion (Ovide) – Medical Necessity Request
Complete this section for members 6 years of age and older.
1. Has the member tried OTC permethrin (e.g., Nix, Rid)? Yes or No
-
If No, can the member try OTC permethrin instead? Yes or No
- If yes, please call the prescription in to the pharmacy.
- If no, please provide the clinical reason why permethrin cannot be tried.
____________________________________________________________
2. What is the diagnosis?
□ Head Lice
□ Pediculosis Pubis (Pubic Lice)
□ Pediculosis Corporis (Body Lice)
- Is the condition severe? Yes or No
□ Other: _________________________________
_____________________________________________________________________________________________________________________
Complete this section for members less than 6 years of age.
1. Has the member tried OTC permethrin (e.g., Nix, Rid)? Yes or No
-
If no, can the member try OTC permethrin instead? Yes or No
- If yes, please call the prescription in to the pharmacy.
- If no, please provide the clinical reason why permethrin cannot be tried.
_______________________________________________________________________
2. For members not being switched to OTC permethrin: Ovide is not indicated for use in children less than 6
years of age. Can the member try either Ulesfia, Natroba, or Sklice? Yes or No
- If yes, please indicate which med will be prescribed. __________________________
- If no, please provide clinical rationale as to why the member cannot try any of these
medications. __________________________________________________________________
3. What is the diagnosis?
□ Head Lice
□ Pediculosis Pubis (Pubic Lice)
□ Pediculosis Corporis (Body Lice)
- Is the condition severe? Yes or No
□ Other: _________________________________
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. 3/16
HNJH Fax #: 888-567-0681
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