Dymista (Azelastine/fluticasone) Medical Necessity Prior Authorization Form Page 2

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Dymista (azelastine/fluticasone)
Medical Necessity Prior Authorization Form
3. Does the participant have a documented contraindication to the listed formulary alternatives (e.g.,
flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex)?
If yes, please submit documentation including medication name(s) and contraindication.
Yes
No
__________________________________________________________________________________
(If yes, skip to question 6.)
4. Has the participant had an adverse reaction to OR would be reasonably expected to have an adverse
reaction to a majority (e.g., two or more in a class with at least two alternatives or one in a class with
only one alternative) of the listed formulary agents used for the requested indication (e.g., flunisolide
spray, fluticasone spray, triamcinolone spray, Nasonex)?
Yes
No
If yes, please submit documentation including medication name(s) and adverse reaction(s).
__________________________________________________________________________________
(If yes, skip to question 6.)
5. Does the participant have a clinical condition for which there is no listed formulary agent to treat the
condition based on published guidelines or clinical literature (e.g., flunisolide spray, fluticasone spray,
triamcinolone spray, Nasonex)?
Yes
No
If yes, please submit documentation including the clinical condition.
__________________________________________________________________________________
6. Is the drug being prescribed within the manufacturer’s published dosing guidelines or does the dose fall
within dosing guidelines found in accepted compendia or current literature (e.g., package insert, AHFS,
Yes
No
Micromedex, current accepted guidelines, etc.)?
I affirm that the information given on this form is accurate as of this date.
Prescriber (or Authorized) Signature:________________________________________ Date:______/______/_20____
Confidential
Page 2 of 2
Revised: January 2013

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