Sublingual Immunotherapy (Grastek, Oralair, Ragwitek) - Medical Necessity Request Form Page 2

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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: __________________
8.
Has member tried and failed intranasal corticosteroids?
□ Yes - Please provide the names of the medications tried:____________________________________________________
□ No – Can the member try an intranasal corticosteroid (Fluticasone, OTC Nasacort 24HR)?
□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 Corticosteroid.
__________________________________________________________________________
__________________________________________________________________________
9.
Has member tried and failed Subcutaneous Allergen Immunotherapy?
□ Yes
□ No – Can the member try Subcutaneous Allergen Immunotherapy?
□Yes
□No - provide the reason why member cannot try Subcutaneous Allergen immunothearpy.
__________________________________________________________________________
__________________________________________________________________________
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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