Rituximab (Rituxan) - Medical Necessity Request Form (Page 2 of 2) in pdf

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

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

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

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

□ Non-Hodgkin's Lymphoma (NHL)

□ Hairy Cell Leukemia

□ Lymphoblastic Lymphoma

a. What type of NHL does the member have?

□ AIDS-related B-cell Lymphoma

□ Mantle cell Lymphoma

□ Burkitt's Lymphoma

□ Non-gastric Malt Lymphoma

□ Chronic Lymphocytic Leukemia/ Small

□ Primary cutaneous B-cell Lymphoma

□ Post-transplant lymphoproliferative

Lymphocytic Lymphoma

□ Diffuse large B-cell Lymphoma

disorder (PTLD)

□ Follicular lymphoma

□ Splenic Marginal Zone Lymphoma

□ Gastric MALT Lymphoma

□ Other: ___________________________

b. Is the condition low-grade? Yes or No

c. Is the condition follicular? Yes or No

d. Is the lymphoma CD-20 positive? Yes or No

e. Is the lymphoma B-cell? Yes or No

f. Is it diffuse large B cell? Yes or No

g. Does member have stable (non-progressing) disease following first-line treatment with CVP chemotherapy? Yes or No

h. What stage is the disease (e.g., I, II, III, IV, T1, T2, etc): _____________

□ Pauci-immune focal and segmental necrotizing glomerulonephritis

a. Does the member have severe disease? Yes or No

b. Is cyclophosphamide contraindicated? Yes or No

c. Does the member have ANCA GN resistant disease? Yes or No

□ Post-Transplant Lymphoproliferative Disorder (PTLD)

a. Is it persistent or progressive? Yes or No

b. Does the member have evidence of allograft rejection? Yes or No

□ Rheumatoid Arthritis

□ Mild

□ Moderate

□ Severe

a. What is the severity of the disease?

b. Is the disease active? Yes or No

c. Is the member also receiving methotrexate?

□ Yes

□ No - Please provide the reason why the member is not receiving methotrexate:

________________________________________________________________________________________________________

d. Has the member had an inadequate response to an oral DMARD? Yes or No

e. Does the member have early Rheumatoid Arthritis with high disease activity and poor prognostic features? Yes or No

f. Has the member tried a self-injectable TNF inhibitor such as Enbrel or Humira?

□ Yes

□ No – Can the member try either Enbrel or Humira instead of Rituxan?

□ Yes – Call the pharmacy with the change. Please note that Enbrel and Humira require prior

authorization.

□ No – Please provide the reason why Enbrel or Humira cannot be tried:

___________________________________________________________________________

g. Is the member being managed by a Rheumatologist? Yes or No

□ Systemic Lupus Erythematosus (SLE)

□ Thrombotic thrombocytopenic purpura (TTP)

□ Waldenstrom's macroglobulinemia / macroglobulinemia/ lymphoplasmacytic lymphoma

□ Wegener's Granulomatosis (WG)/granulomatosis with polyangiitis and Microscopic Polyangiitis (MPA)

a. Will the member also be receiving glucocorticoids? 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

2 of 2

Rev. 03/16

HNJH Fax #: 888-567-0681

Page

Rituximab (Rituxan) - Medical Necessity Request Form Page 2

Related Articles

Related forms

Related Categories