Botox Or Myobioc Prior Authorization Form - Prescriber'S Statement Of Medical Necessity

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PRESCRIBER’S STATEMENT OF MEDICAL NECESSITY
Prior-Authorization –Botox (botulinum toxin type A) or Myobloc (botulinum toxin type B)
Maryland Pharmacy Program, Division of Pharmacy Services
Tel#: 410-767-1455 or 1-800-492-5231 Option 3
Fax form to: 410-333-5398 (Incomplete forms will be returned)
______________________________________________________________________________________________________
Patient Information
Patient location:  home  hospital  Nursing Home- Injection to be given at  Office  Clinic  Nursing Home 
Hospital
Patient Name:____________________________________
Address: ____________________________________________
MA ID#:________________________________________
____________________________________________
Tel.#: (_______) __________-__________ Body Weight________kg or_______lb
Birthdate__________Sex: M____F___
________________________________________________________________________________________________________
Prescription Information
RX- Circle :
Botox
Myobloc
Dispense: # vials: _________________
Units per vial: _____________________
Sig: _____________________________________________________________Repeat every______ months.
Anticipated length of therapy: _________________________________________
Request for:
Initiation of therapy
Continuation of therapy
Scheduled injection date:______/_____/_____
List other therapies tried:__________________________________________________________________________________
______________________________________________________________________________________________________
Please answer all questions:
1.
Indications for which Botox/Myobloc has been prescribed:
________________________________________________________________________________________________
2.
Number of units to be injected per injection site:__________________________________________________________
3.
Number of sites to be injected:________________________________________________________________________
4.
Specific sites of injection:___________________________________________________________________________
5.
Frequency of injections (no more than once every 90 days recommended):_____________________________________
6.
Specify off-label use*, if applicable: __________________________________________________________________
_______________________________________________________________________________________________
* Cosmetic use of Botox/Myobloc will not be approved. All other unlabelled uses must be safe and medically necessary.
Evidence of clinical benefits must be demonsstrated and supported by peer-reviewed literature and any one of the three
official compendia, the American Hospital Formulary Service, the U.S.P. Pharmacopeia Drug Information, or the
Micromedex Drugdex database.
Clinical Prior Authorization is required and will be granted per treatment due to possible changes in dosage and injection
sites. A separate Prior-Auth Request form is required to be completed every 3 months. Prescribers may not bill the Botox
under Physicians Services if medication is paid under Pharmacy Services.
I certify that this treatment is medically necessary. I will be supervising the treatment accordingly. Supporting medical
documentation is available in the patient record.
___________________________________, M.D.
Prescriber’s Name:_____________________________________________
Prescriber’s signature
Date:___________
Address: _____________________________________________________
Tel# (_______) – __________- _________Fax#(_______) - _________ - _________ _____________________________________________
Pharmacy Information
Pharmacy: ________________________________________________________________________________________
Phone # (________)_____________________ Fax # (__________) ____________-________________
Claims submitted on-line will deny for service prior-authorization. Pharmacists are to call the State at 410-767-1755 or 1-800-492-
5231, Option 3 for an override for each Botox/Myobloc prescription. Enter a 90-day supply for each prescription.
_______________________________________________________________________________________________________-
Prior-Auth Determination:
 Approved
Date_______________________
 Denied______Reason_________________________________________
C:\Word\BotoxPAFormJun08

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