Hmo Part B Drug Prior Authorization Request Form Page 2

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DIAGNOSIS (select one)
Moderate-to-severe persistent asthma
Chronic idiopathic urticaria
Other_________________________________________________________________________________________
CLINICAL INFORMATION. PLEASE ATTACH SUPPORTING DOCUMENTATION, INCLUDING LABS, RESULTS OF
DIAGNOSTIC TESTS, AND OFFICE VISIT NOTES.
Asthma, newly starting Xolair:
Has the patient has had a positive skin test OR in vitro reactivity to a perennial aeroallergen (e.g. positive RAST test)?
Yes
No. Please explain ________________________________________________________________
Pre-treatment serum IgE level_________________________________ IU/ml Date: ___________________________
Has the patient taken high dose inhaled steroids with a long-acting bronchodilator for at least 3 months?
Yes
No. If no, please explain why_______________________________________________________
Is there documentation of any of the following?
Yes Check all that apply.
No
Requires daily use of an inhaled short-acting beta-agonist
FEV1<60% predicted
ER/urgent care visits or hospitalization for asthma exacerbation in the past 12 months
Limited physical activity or activity affected by exacerbations due to asthma
Frequent exacerbations
Asthma, Reauthorization request for continued treatment:
Has treatment with Xolair has resulted in clinical improvement as documented by one or more of the following?
Yes. Check all that apply.
No. Please explain rationale for continued use_______________________
Decreased use of rescue inhaled beta-agonists
Decreased frequency of asthma exacerbations (defined as worsening of asthma that requires increase in
inhaled corticosteroid dose or treatment with systemic corticosteroids)
Increase in percent predicted FEV1 from baseline
Reduction in reported symptoms as documented by decrease in frequency or severity of one or more of
the following:
Asthma attacks
Chest tightness or heaviness
Wheezing
Difficulty taking a deep breath or breathing out
Shortness of breath
Nighttime symptoms
Coughing or clearing throat
Chronic idiopathic urticaria:
Does the patient have a documented inadequate response to an antihistamine?
Yes
No
Feel free to provide additional information you feel is relevant to the request below:
Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.
15-071_H6453
18NW2246 11/15
Blue Advantage from HMO Louisiana, Inc. is an HMO plan with a Medicare contract. HMO Louisiana is a subsidiary of
Blue Cross and Blue Shield of Louisiana, independent licensees of the Blue Cross and Blue Shield Association.

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