Form FA-87 "Prolia (Denosumab) Prior Authorization Request Form" - Nevada

What Is Form FA-87?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 6, 2021;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FA-87 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form FA-87 "Prolia (Denosumab) Prior Authorization Request Form" - Nevada

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Nevada Medicaid
rex
Submit fax request to: 855-455-3303
Please note: All information below is required to process this request.
Prolia® (denosumab)
Prior Authorization Request Form
DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED.
Member Information
Provider Information
(required)
(required)
Member Name:
Provider Name:
Insurance ID#:
NPI#:
Specialty:
Date of Birth:
Office Phone:
Street Address:
Office Fax:
City:
State:
Zip:
Office Street Address:
Phone:
City:
State:
Zip:
Medication Information
(required)
Medication Name:
Strength:
Dosage Form:
❑ Check if requesting brand
Directions for Use:
❑ Check if request is for initial therapy
❑ Check if request is for recertification of therapy
Clinical Information
(required)
Select the diagnosis below:
❑ Diagnosis of postmenopausal osteoporosis or osteopenia
❑ Diagnosis of nonmetastatic prostate cancer (undergoing androgen deprivation therapy or bilateral orchiectomy)
❑ Diagnosis of breast cancer (receiving adjuvant aromatase inhibitor therapy)
❑ Diagnosis of glucocorticoid-induced osteoporosis (recipient has a documented history of prednisone or its equivalent at a dose greater
than or equal to 7.5 mg/day for greater than or equal to six months).
❑ Other diagnosis: ___________________________________
ICD-10 Code(s): ___________________________________
Drug-Specific Information
(required)
❑ The recipient’s Bone Mineral Density (BMD) T-score is -2.5 or lower in the lumbar spine, femoral neck, total hip, or radius (one-third
radius site).
❑ The recipient is 70 years of age or older.
❑ The recipient has a BMD T-score between -1.0 and -2.5 in the lumbar spine, femoral neck, total hip, or radius (one-third radius site).
❑ The recipient has documented history of low-trauma fracture of the hip, spine, proximal humerus, pelvis, or distal forearm.
❑ The recipient has documented trial and failure, contraindication, or intolerance to one anti-resorptive treatment (e.g., alendronate,
risedronate, zoledronic acid).
❑ The recipient has a FRAX 10-year probability of a major osteoporotic fracture at 20% or more in the U.S., or the country-specific
threshold in other countries or regions.
❑ The recipient has a FRAX 10-year probability of a hip fracture at 3% or more in the U.S., or the country-specific threshold in other
countries or regions.
Reauthorization:
❑ The recipient has documented benefit from therapy.
❑ The recipient has a diagnosis of nonmetastatic prostate cancer and continues androgen depravation therapy or bilateral orchiectomy.
❑ The recipient has no evidence of metastases.
❑ The recipient has a diagnosis of breast cancer and continues adjuvant aromatase inhibitor therapy.
Attach any additional comments, diagnoses, symptoms, medications tried or failed, or other information the physician feels is important to this review.
Please note:
This request may be denied unless all required information is received. For urgent or expedited requests please call 1-800-711-4555.
This form may be used for non-urgent requests and faxed to 1-800-527-0531.
This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider
named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI
between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using
information in this document is against the law. If you are not the intended recipient, please notify the sender immediately.
FA-87
04/06/2021 pv07/18/2017
Page 1 of 1
Nevada Medicaid
rex
Submit fax request to: 855-455-3303
Please note: All information below is required to process this request.
Prolia® (denosumab)
Prior Authorization Request Form
DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED.
Member Information
Provider Information
(required)
(required)
Member Name:
Provider Name:
Insurance ID#:
NPI#:
Specialty:
Date of Birth:
Office Phone:
Street Address:
Office Fax:
City:
State:
Zip:
Office Street Address:
Phone:
City:
State:
Zip:
Medication Information
(required)
Medication Name:
Strength:
Dosage Form:
❑ Check if requesting brand
Directions for Use:
❑ Check if request is for initial therapy
❑ Check if request is for recertification of therapy
Clinical Information
(required)
Select the diagnosis below:
❑ Diagnosis of postmenopausal osteoporosis or osteopenia
❑ Diagnosis of nonmetastatic prostate cancer (undergoing androgen deprivation therapy or bilateral orchiectomy)
❑ Diagnosis of breast cancer (receiving adjuvant aromatase inhibitor therapy)
❑ Diagnosis of glucocorticoid-induced osteoporosis (recipient has a documented history of prednisone or its equivalent at a dose greater
than or equal to 7.5 mg/day for greater than or equal to six months).
❑ Other diagnosis: ___________________________________
ICD-10 Code(s): ___________________________________
Drug-Specific Information
(required)
❑ The recipient’s Bone Mineral Density (BMD) T-score is -2.5 or lower in the lumbar spine, femoral neck, total hip, or radius (one-third
radius site).
❑ The recipient is 70 years of age or older.
❑ The recipient has a BMD T-score between -1.0 and -2.5 in the lumbar spine, femoral neck, total hip, or radius (one-third radius site).
❑ The recipient has documented history of low-trauma fracture of the hip, spine, proximal humerus, pelvis, or distal forearm.
❑ The recipient has documented trial and failure, contraindication, or intolerance to one anti-resorptive treatment (e.g., alendronate,
risedronate, zoledronic acid).
❑ The recipient has a FRAX 10-year probability of a major osteoporotic fracture at 20% or more in the U.S., or the country-specific
threshold in other countries or regions.
❑ The recipient has a FRAX 10-year probability of a hip fracture at 3% or more in the U.S., or the country-specific threshold in other
countries or regions.
Reauthorization:
❑ The recipient has documented benefit from therapy.
❑ The recipient has a diagnosis of nonmetastatic prostate cancer and continues androgen depravation therapy or bilateral orchiectomy.
❑ The recipient has no evidence of metastases.
❑ The recipient has a diagnosis of breast cancer and continues adjuvant aromatase inhibitor therapy.
Attach any additional comments, diagnoses, symptoms, medications tried or failed, or other information the physician feels is important to this review.
Please note:
This request may be denied unless all required information is received. For urgent or expedited requests please call 1-800-711-4555.
This form may be used for non-urgent requests and faxed to 1-800-527-0531.
This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider
named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI
between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using
information in this document is against the law. If you are not the intended recipient, please notify the sender immediately.
FA-87
04/06/2021 pv07/18/2017
Page 1 of 1