Rituximab (Rituxan) - Medical Necessity Request Form

ADVERTISEMENT

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Rituximab (Rituxan) – Medical Necessity Request
General Information:
1. Is the member receiving radiation therapy? Yes or No
2. Will the member be receiving any other therapy (e.g., chemotherapy, radiation, ACE/ARBS, etc) in combination with Rituxan?
□ Yes – Please provide the name(s) of the other agents: ___________________________________
________________________________________________________________________________
□ No
3. Has the member previously received any other therapy for this condition?
□ Yes – Please provide the name(s) of the agents: ________________________________________
________________________________________________________________________________
□ No
3. Is the condition refractory? Yes or No
4. Is the condition recurrent or progressive? Yes or No
5. Is the condition relapsed? Yes or No
Diagnosis Information (please indicate diagnosis and answer related questions):
□ Acute Lymphocytic Leukemia (ALL)
□ Multiple Myeloma
a. Is Rituxan being used for induction or consolidation
a. Does the member have Waldenstrom's
therapy? Yes or No
macroglobulinemia? Yes or No
b. Is the member Philadelphia chromosome positive or
□ Primary Central Nervous System Lymphoma
negative?
□ Positive
□ Negative
□ Autoimmune Hemolytic Anemia (AIHA) – Please indicate the
type below and answer related questions.
□ Warm AIHA
a. Is the member corticosteroid-refractory or
corticosteroid-dependent? Yes or No
□ Cold agglutination syndrome
□ Chronic Lymphocytic Leukemia (CLL)
a. Is the member also receiving fludarabine and
cyclophosphamide? Yes or No
□ Hodgkin's Disease/Lymphoma
a.
Is it lymphocyte-predominant? Yes or No
b.
What stage is the disease (e.g., I, II, III, IV):
_____________
□ Idiopathic thrombocytopenic purpura (ITP)
□ Lupus Nephritis
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
Page

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2