Form Pca18558 - Enzyme Replacement Therapy For Gaucher Disease Prior Authorization Form
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1
2Enzyme Replacement Therapy for Gaucher Disease
Prior Authorization Form
Please complete this form for UnitedHealthcare members needing an Enzyme Replacement Therapy
prescription. Fax the completed form to UnitedHealthcare at 800-743-6829.
UnitedHealthcare will notify you and your patient of prescription approval.
This form helps UnitedHealthcare determine if the patient’s condition meets our drug policy guidelines.
Please fill out the form completely. Any missing information may cause a delay in the approval.
Fax: 800-743-6829 | Phone: 866-604-3267 or 800-690-1606
Patient Information
Patient’s Name: ________________________________________________________________________ Gender:
M
F
Insurance ID: ____________________________________________ Date of Birth: _________________ Weight: __________________________
Address: _____________________________________________________________________________
Apartment #: _____________________
City: ___________________________________________________
State: _______________________ Zip Code: ________________________
Phone Number: __________________________________________
Alternate Phone Number: _________________________________________
Please attach the front and back side of the member’s insurance card.
Prescriber Information
Name: _________________________________________________
Tax ID: ________________________________________________________
Address: _____________________________________________________________________________
Suite #: _________________________
City: ___________________________________________________ State: _______________________
Zip Code: ________________________
Phone Number: __________________________________________ Fax Number: ___________________________________________________
Office Contact: __________________________________________
Contact Phone / Extension: ________________________________________
Diagnosis Information
As appropriate, please attach clinical information supporting stated diagnosis, including medication(s) previously tried and failed and
laboratory reports. Reference drug policy for diagnosis specific requirements at unitedhealthcareonline.
E75.22 – Gaucher Disease
Other ___________________________________________________
Please also specify:
Type 1 Gaucher
Type 2 Gaucher
Type 3 Gaucher
Clinical Information
Is the patient new to therapy:
Yes
No
If yes, provide the following: Requested start date: _______________
If no, provide the following:
Start date: ________________
Date of last dose: ________________
Will the physician supply the medication?:
Yes
No
If no, who will supply the medication?:
Accredo
BioScrip
Caremark
Option Care
Other (Name, Address, City, State, Zip): ____________________________________________________________________________
Site of care:
Infusion Center
Physician’s Office
Home Health with Nursing (Name, Address, City, State, Zip): _____________________________________________________________
Duration of treatment: _____________________________________________________________________________________________________
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