Immunomodulators Atopic Dermatitis - Prior Authorization Form Pa
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1Office of Medical Assistance Programs
Fee-for-Service, Pharmacy Division
Phone 1-800-537-8862 Fax 1-866-327-0191
IMMUNOMODULATORS, ATOPIC DERMATITIS
PRIOR AUTHORIZATION FORM
Please submit all requested documentation with this request. Incomplete documentation may delay the processing of this
request.
To review the prior authorization guidelines for Immunomodulators, Atopic Dermatitis agents, please refer to the Medical Assistance
Prior Authorization of Pharmaceutical Services Handbook Chapter – Immunomodulators, Atopic Dermatitis (accessible at:
).
PRIOR AUTHORIZATION INFORMATION
PRESCRIBER INFORMATION
New request
Additional info
# of pages in request:
Renewal request
(PA# _______________)
________________
Prescriber name:
Name of office contact:
Specialty:
Contact’s phone number:
State license #:
LTC facility
MA Provider
NPI:
contact/phone:
ID#:
RECIPIENT INFORMATION
Street address:
Recipient Name:
Suite #:
City/state/zip:
Recipient ID#:
DOB:
Phone:
Fax:
CLINICAL INFORMATION
Protopic 0.03% ointment
tacrolimus 0.03% ointment
Non-preferred medication requested
:
Protopic 0.1% ointment
tacrolimus 0.1% ointment
Directions:
Quantity:
Refills:
Diagnosis (submit documentation):
D
code (required):
X
Yes – submit all supporting documentation of
1. Does the Recipient have a history of trial and failure, contraindication, or
preferred agent tried and treatment outcome,
intolerance of the preferred Immunomodulators, Atopic Dermatitis agent, Elidel 1%
including contraindications or intolerances
cream?
No
PLEASE FAX COMPLETED FORM WITH REQUIRED CLINICAL DOCUMENTATION TO DHS –
PHARMACY DIVISION
Prescriber Signature:
Date:
Confidentiality Notice: The documents accompanying this telecopy may contain confidential information belonging to the sender. The information is intended only
for the use of the individual named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any
telecopy is strictly prohibited.
Form effective 3/9/16
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