Form Pca18563 - Immune Globulin (Ivig And Scig) Prior Authorization Form
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1
2Immune Globulin (IVIG and SCIG)
Prior Authorization Form
Please complete this form for UnitedHealthcare members needing an Immune Globulin prescription.
Fax the completed form to UnitedHealthcare at 855-554-2152.
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: 855-554-2152 | Phone: 866-604-3267
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
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
C91.10 – Chronic lymphocytic leukemia of B-cell type not
G35 – Multiple Sclerosis
having achieved remission
D69.3 – Immune thrombocytopenic purpura
G40.81 – Lennox-Gastaut syndrome
D80.0 – Hereditary hypogammaglobulinemia
G61.0 – Guillain-Barre syndrome
D80.1 – Nonfamilial hypogammaglobulinemia
G61.81 – Chronic inflammatory demyelinating polyneuritis
D81.2 – Severe combined immunodeficiency [SCID] with
G70.01 – Myasthenia gravis with (acute) exacerbation
low or normal B-cell numbers
D83.0 – Common variable immunodeficiency with
G70.81 – Lambert-Eaton syndrome in disease classified elsewhere
predominant abnormalities of B-cell numbers and function
D83.8 – Other common variable immunodeficiencies
M33.22 – Polymyositis with myopathy
D89.9 – Disorder involving the immune mechanism,
M33.99 – Dermatopolymyositis, unspecified with other
unspecified
organ involvement
G25.82 – Stiff-man syndrome
Other____________________________________________________
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