Sublingual Immunotherapy (Grastek, Oralair, Ragwitek) - 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
Sublingual Immunotherapy (Grastek, Oralair, Ragwitek) – Medical Necessity Request
What date did the member start or is planning to start therapy? _____________
What is the requested length of therapy? ___________
Contraindication Information:
□ Severe, unstable or uncontrolled asthma
□ History of any severe systemic allergic reaction
□ History of any severe local reaction after taking any
□ History of Eosinophilic Esophagitis
□ Hypersensitivity to any of the inactive ingredients
sublingual allergen immunotherapy
□ None
Diagnosis Information (please indicate diagnosis and answer related questions):
1.
What is member being treated for?
□ Grass pollen induced allergic rhinitis
□ Ragweed pollen induced allergic rhinitis □ Other____________________________
□ Other____________________________
Which specialist is prescribing the medication: □ Allergist □ Immunologist
2.
3.
Will the first dose be administered in the healthcare setting? Yes or No
4.
Does member have an active prescription for an epinephrine injection? Yes or No
5.
Did member have a positive skin prick test or in vitro testing for pollen-specific IgE antibodies? Yes or No
- If Yes, please indicate which pollen-specific antibody tested positive:
□ Sweet Vernal
□ Timothy
□ Other: __________________________
□ Orchard
□ Kentucky Blue Grass
□ Perennial Rye
□ Ragweed
6.
Has member tried and failed oral antihistamines?
□ Yes - Please provide the names of the medications tried:____________________________________________________
□ No – Can the member try an oral antihistamine (OTC cetirizine, OTC loratadine, Fexofenadine 60mg or 180mg, OTC
Allegra-D)?
□Yes - please provide the name of the new medication, call the prescription for the
new medication into the pharmacy, then return form to HNJH.________________________
□No - provide the reason why member cannot try an oral antihistamine.
__________________________________________________________________________
__________________________________________________________________________
7.
Has member tried and failed intranasal antihistamines?
□ Yes - Please provide the names of the medications tried:____________________________________________________
□ No – Can the member try an intranasal antihistamine (Generic Astelin)?
□Yes - please provide the name of the new medication, call the prescription for the
new medication into the pharmacy, then return form to HNJH.________________________
□No - provide the reason why member cannot try an intranasal antihistamine.
__________________________________________________________________________
__________________________________________________________________________
(Continued on p. 2)
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