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Healthpartners.org

PRIOR AUTHORIZATION REQUEST FORM
Risperdal Consta® (Risperidone)r
rPhone: 215-991-4300rFax back to: 866-240-3712 r
HEALTH PARTNERS manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician.
Please answer the following questions and fax this form to the number listed above. Please print clearly.
Patient Name:NA
Physician Name:NA
Please answer the following questions and sign below:
Q1. What is the requested duration of therapy?. r6 months or less. rMore than 6 months Q2. What is the patient's age?. rLess than 18 years Q3. What is the patient's diagnosis?. rSchizophrenia. rOther Q4. If other, please provide the diagnosis below.
Q5. Does the patient have a long-term history (> 3 months) of oral anti-psychotic medication noncompliance?. rYes. rNo Q6. Does documentation submitted indicate significant clinical decompensation or is there a high risk for decompensationand functional impairment (e.g., hospitalizations, safety risk) ?. rYes. rNo Q7. Does documentation submitted on a drug adherence treatment plan indicate that the patient failed the following typesof measures to improve compliance with formulary oral medications and/or a reason why any of the following measureswere not implemented to improve compliance with formulary oral medication as clinically applicable: (check all that apply). ri. Psychosocial interventions . rii. Psychoeducational interventions that have a behavioral component and supportive services . riii. Provided member with concrete instructions and problem-solving strategies (i.e., reminders, self-monitoring tools, cues and reinforcements). rDoes the patient have a documented medical reason (i.e., documented treatment failure to maximum doses and/or intolerable side effects or drug interactions) for not using formulary atypical antipsychotic agents?. rNone of these Q8. Does the patient have a documented history of receiving a minimum of 2 mg of oral Risperdal daily without anyclinically significant side effects? PRIOR AUTHORIZATION REQUEST FORM
Risperdal Consta® (Risperidone)r
rPhone: 215-991-4300rFax back to: 866-240-3712 r
HEALTH PARTNERS manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician.
Please answer the following questions and fax this form to the number listed above. Please print clearly.
Patient Name:NA
Physician Name:NA
Q9. Deliver to:. rPhysician's Office. rHome Delivery Physician Signature
This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual orentity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you arehereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy inerror, please notify the sender immediately to arrange for the return of this document.

Source: http://healthpartners.org/pdf/PharmacyRequestForm/RisperdalConstaInitial.pdf

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