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Microsoft word - sym_immuno_fax_form_0613
Systemic Immunomodulators Medication
New Hampshire Medicaid Prior Authorization Request Form
Fax to Magellan if medication is to be dispensed from a pharmacy
Magellan: Fax: 1‐888‐603‐7696
Fax to KePRO if medication is dispensed/administered by a physician in the office or outpatient setting:
KePRO: Fax: 1‐800‐922‐9847
DATE OF MEDICATION REQUEST:
Section I: Patient Information and Medication Request
NAME (LAST, FIRST):
NH MEDICAID NUMBER:
DATE OF BIRTH:
NUMBER OF INJECTIONS REQUIRED/REQUESTED:
LENGTH OF THERAPY:
Section II: Clinical History
Previous failure, contraindication, or adverse reaction to methotrexate AND at least one DMARD (sulfasalazine,
hydroxychloroquine, minocylcine): (For diagnosis of Rheumatoid Arthritis only)
Previous failure, contraindication, or adverse reaction to IV cycosporine AND azathioprine or mercaptopurine for
three months AND diagnosis of fistula by colonic endoscopy: (For diagnosis of Fistulizing Crohn’s Disease only)
Previous failure, contraindication, or adverse reaction to oral corticosteroid AND azathioprine or mercaptopurine for
three months AND parenteral methotrexate for three months: (For diagnosis of Crohn’s disease)
Previous failure, contraindication, or adverse reaction to oral/rectal aminosalicylate AND oral corticosteroid AND
azathioprine or mercaptopurine for three months:
(For diagnosis of active ulcerative colitis)
Previous failure, contraindication, or adverse reaction to topical psoriasis agents:
(For diagnosis of severe chronic plaque psoriasis only)
Does the patient have a diagnosis of moderate to severe heart failure?
Is the patient pregnant? (Female only)
Is the patient currently on another systemic immunomodulator?
11. Is there any additional information that would help in the decision-making process?
Section III: Non-Preferred Drug Approval Criteria
Chapter 188 of the Laws of 2004 requires that Medicaid only cover non‐preferred drugs upon a finding of medical necessity by the prescribing physician. Chapter 188 requires that you base your determination of medical necessity on the following criteria.
Previous episode of an unacceptable side effect or therapeutic failure
Clinical contraindication, co-morbidity, or unique patient circumstance as a contraindication to a
Unique clinical indication supported by FDA approval or peer
Unacceptable clinical risk associated with therapeutic change
Section IV: Prescriber Information
GROUP MEDICAID ID #:
MEDICAID PROVIDER ID #:
NAME (LAST, FIRST):
NPI MEDICAID NUMBER:
I certify that the information provided is accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to civil or criminal liability.
Signature of Prescribing Provider
IF APPLICABLE: FACILITY WHERE INFUSION TO BE PROVIDED:
Proprietary & Confidential 2013, Magellan Health Services, Inc. All Rights Reserved.
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