Dymista (Azelastine/fluticasone) Medical Necessity Prior Authorization Form

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Dymista (azelastine/fluticasone)
Medical Necessity Prior Authorization Form
Patient Information
Name:
Insurance ID #:
Phone #:
Date of Birth:
Diagnosis:
Diagnosis Code:
Provider Information
Prescriber’s Name:
Phone:
Fax:
Office Address:
After you complete this form, please sign and date it. Fax it to Caremark at 888-836-0730.
Caremark is an independent company that administers the prior authorization program on behalf
of the member’s health plan. The Caremark fax machine is in a HIPAA-compliant secure location.
Call Caremark at 800-294-5979 with any questions concerning prior authorization procedures.
Members should call Caremark Customer Care at 888-963-7290 with any questions. Members
can also call their health plans at the numbers on their ID cards.
Formulary Alternatives:
•
flunisolide spray
•
fluticasone spray
•
triamcinolone spray
•
Nasonex
Please circle the appropriate answer for each applicable question.
1. Is the requested drug being prescribed for an FDA-approved indication?
Yes
No
(If no, then no further questions.)
2. Has the participant demonstrated a failure of or intolerance to a majority (i.e., two or more in a class
with at least two alternatives or one in a class with only one alternative) of the preferred
formulary/preferred drug list alternatives for the given diagnosis (e.g., flunisolide spray, fluticasone
spray, triamcinolone spray, Nasonex)?
If yes, please submit documentation including medication(s) tried, dates of trial(s) and reason for
Yes
No
treatment failure(s):
__________________________________________________________________________________
(If yes, skip to question 6.)
Confidential
Page 1 of 2
Revised: January 2013

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