Form FA-83 "Monoclonal Antibody Agents Prior Authorization Request Form" - Nevada

What Is Form FA-83?

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 August 3, 2020;
  • 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-83 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-83 "Monoclonal Antibody Agents 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.
Monoclonal Antibody Agents
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 continuation of therapy
Drug-Specific Information
(required)
Cinqair® (reslizumab)
Will the recipient use the requested antiasthmatic monoclonal antibody in combination with other antiasthmatic monoclonal
antibodies?
Yes
No
What is the recipient’s diagnosis?
Severe eosinophilic-phenotype asthma
.
Other: ________________________ ICD-10 Code(s): _____________________
Is the recipient 18 years of age or older?
Yes
No
Is the medication prescribed by or in consultation with a pulmonologist or an allergist/immunologist?
Yes
No
Is the recipient uncontrolled on current therapy that includes a high dose corticosteroid?
Yes
No
Is the recipient on a secondary asthma inhaler?
Yes
No
Is the requested dose to be 3mg/kg via intravenous infusion of 20 to 50 minutes every four weeks?
Yes
No
If no, please provide the requested dose: _______________________________________________________________
Will the prescriber submit documentation of the recipient’s vaccination status along with this request?
Yes
No
Dupixent® (dupilumab)
Please select the recipient’s diagnosis below and answer the following diagnosis-related questions:
Atopic Dermatitis
Does the recipient have a diagnosis of moderate to severe atopic dermatitis?
Yes
No
Does the recipient have a trial and failure, contraindication, or intolerance to one medium to high potency topical
corticosteroid (e.g., betamethasone, triamcinolone)?
Yes, drug/response:__________________________________________________________________
No
Does the recipient have a trial and failure or intolerance to any of the following?
Tacrolimus topical ointment
Elidel® (pimecrolumus) topical cream
Recipient is not a candidate for therapy
(e.g., immunocompromised)
Is the medication prescribed by or in consultation with a dermatologist or an allergist/immunologist?
Yes
No
Is the request for recertification of Dupixent®?
Yes
No
If yes, is there documentation of positive clinical response to Dupixent®?
Yes (attach documentation)
No
(Dupixent® (dupilumab) criteria continued on next page)
FA-83 08/03/2020
Page 1 of 4
Nevada Medicaid
rex
Submit fax request to: 855-455-3303
Please note: All information below is required to process this request.
Monoclonal Antibody Agents
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 continuation of therapy
Drug-Specific Information
(required)
Cinqair® (reslizumab)
Will the recipient use the requested antiasthmatic monoclonal antibody in combination with other antiasthmatic monoclonal
antibodies?
Yes
No
What is the recipient’s diagnosis?
Severe eosinophilic-phenotype asthma
.
Other: ________________________ ICD-10 Code(s): _____________________
Is the recipient 18 years of age or older?
Yes
No
Is the medication prescribed by or in consultation with a pulmonologist or an allergist/immunologist?
Yes
No
Is the recipient uncontrolled on current therapy that includes a high dose corticosteroid?
Yes
No
Is the recipient on a secondary asthma inhaler?
Yes
No
Is the requested dose to be 3mg/kg via intravenous infusion of 20 to 50 minutes every four weeks?
Yes
No
If no, please provide the requested dose: _______________________________________________________________
Will the prescriber submit documentation of the recipient’s vaccination status along with this request?
Yes
No
Dupixent® (dupilumab)
Please select the recipient’s diagnosis below and answer the following diagnosis-related questions:
Atopic Dermatitis
Does the recipient have a diagnosis of moderate to severe atopic dermatitis?
Yes
No
Does the recipient have a trial and failure, contraindication, or intolerance to one medium to high potency topical
corticosteroid (e.g., betamethasone, triamcinolone)?
Yes, drug/response:__________________________________________________________________
No
Does the recipient have a trial and failure or intolerance to any of the following?
Tacrolimus topical ointment
Elidel® (pimecrolumus) topical cream
Recipient is not a candidate for therapy
(e.g., immunocompromised)
Is the medication prescribed by or in consultation with a dermatologist or an allergist/immunologist?
Yes
No
Is the request for recertification of Dupixent®?
Yes
No
If yes, is there documentation of positive clinical response to Dupixent®?
Yes (attach documentation)
No
(Dupixent® (dupilumab) criteria continued on next page)
FA-83 08/03/2020
Page 1 of 4
Dupixent® (dupilumab) continued
Moderate to Severe Asthma
Is the recipient 12 years of age or older?
Yes
No
Is the recipient currently dependent on oral corticosteroids for the treatment of asthma?
Yes
No
Is the recipient’s asthma of the eosinophilic phenotype as defined by a baseline (pre-treatment) peripheral blood
eosinophil level greater than or equal to 150 cells per microliter?
Yes
No
Select any of the following that apply to the recipient:
One or more asthma exacerbations requiring systemic corticosteroids within the past 12 months
Any prior intubation for an asthma exacerbation
Prior asthma-related hospitalization within the past 12 months
Is the recipient currently utilizing one maximally dosed combination ICS/LABA product (e.g., Advair® [fluticasone
propionate/salmeterol], Dulera® [mometasone/formoterol], Symbicort® [budesonide/formoterol])?
Yes
No
Recipient has contraindication/intolerance
Is the recipient currently utilizing both a high-dose inhaled corticosteroid (ICS) (e.g., greater than 500 mcg fluticasone
propionate equivalent/day) and an additional asthma controller medication (e.g., leukotriene receptor antagonist,
long-acting beta-2 agonist (LABA), theophylline)?
Yes
No
Recipient has contraindication/intolerance
Is the medication prescribed by or in consultation with a pulmonologist or an allergist/immunologist?
Yes
No
Is the request for recertification of Dupixent®?
Yes
No
If yes, is there documentation of a positive clinical response to Dupixent® therapy (e.g., reduction in exacerbations,
improvement in FEV1, reduction in oral corticosteroid dose)?
Yes (attach documentation)
No
Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)
Has the recipient had an inadequate response to two months of treatment with an intranasal corticosteroid (e.g.,
fluticasone, mometasone)?
Yes
No
Recipient has contraindication/intolerance
If yes, please document drug(s), dose, duration, and date of trial: _______________________________________
___________________________________________________________________________________________
Will the medication be used in combination with another agent for CRSwNP?
Yes
No
Is the medication prescribed by or in consultation with an allergist/immunologist?
Yes
No
Is the request for recertification of Dupixent®?
Yes
No
If yes, is there documentation of a positive clinical response to Dupixent® therapy?
Yes
No
Other diagnosis: ________________________________ ICD-10 Code(s): _________________________________
Fasenra® (benralizumab)
Will the recipient use the requested antiasthmatic monoclonal antibody in combination with other antiasthmatic monoclonal
antibodies?
Yes
No
What is the recipient’s diagnosis?
Severe eosinophilic-phenotype asthma
.
Other: ________________________ ICD-10 Code(s): _____________________
Is the recipient 12 years of age or older?
Yes
No
Select any of the following that apply to the recipient:
Two or more asthma exacerbations requiring systemic corticosteroids within the past 12 months
Any prior intubation for an asthma exacerbation
Prior asthma-related hospitalization within the past 12 months
Is the recipient currently utilizing one maximally dosed combination ICS/LABA product (e.g., Advair® [fluticasone
propionate/salmeterol], Dulera® [mometasone/formoterol], Symbicort® [budesonide/formoterol])?
Yes
No
Recipient has contraindication/intolerance
Is the recipient currently utilizing both a high-dose inhaled corticosteroid (ICS) (e.g., greater than 500 mcg fluticasone
propionate equivalent/day) and an additional asthma controller medication (e.g., leukotriene receptor antagonist, long-acting
beta-2 agonist (LABA), theophylline)?
Yes
No
Recipient has contraindication/intolerance
(Fasenra® (benralizumab) criteria continued on next page)
FA-83 08/03/2020
Page 2 of 4
Fasenra® (benralizumab) continued
Is the medication prescribed by or in consultation with a pulmonologist or an allergist/immunologist?
Yes
No
Is the request for recertification of Fasenra®?
Yes
No
If yes, is there documentation of a positive clinical response to Fasenra® therapy?
Yes
No
Nucala® (mepolizumab)
Please select the recipient’s diagnosis below and answer the following diagnosis-related questions:
Severe Asthma
Is the recipient’s asthma of the eosinophilic phenotype as defined by a baseline (pre-treatment) peripheral blood
eosinophil level greater than or equal to 150 cells per microliter OR peripheral blood eosinophil levels greater
than or equal to 300 cells/microliter from within the past 12 months?
Yes
No
Is the recipient 6 years of age or older?
Yes
No
Select any of the following that apply to the recipient:
One or more asthma exacerbations requiring systemic corticosteroids within the past 12 months
Any prior intubation for an asthma exacerbation
Prior asthma-related hospitalization within the past 12 months
Is the recipient currently utilizing one maximally dosed combination ICS/LABA product (e.g., Advair® [fluticasone
propionate/salmeterol], Dulera® [mometasone/formoterol], Symbicort® [budesonide/formoterol])?
Yes
No
Recipient has contraindication/intolerance
Is the recipient currently utilizing both a high-dose inhaled corticosteroid (ICS) (e.g., greater than 500 mcg fluticasone
propionate equivalent/day) and an additional asthma controller medication (e.g., leukotriene receptor antagonist,
long-acting beta-2 agonist (LABA), theophylline)?
Yes
No
Recipient has contraindication/intolerance
Is the medication prescribed by or in consultation with a pulmonologist or an allergist/immunologist?
Yes
No
Is the request for recertification of Nucala®?
Yes
No
If yes, answer the following:
Is there documentation of a positive clinical response to Nucala® therapy (e.g., reduction in exacerbations,
improvement in forced expiratory volume in one second [FEV1], decreased use of rescue medications)?
Yes (attach documentation)
No
Is the recipient currently utilizing a combination ICS/LABA product, or an ICS and an additional asthma controller
medication?
Yes
No
Eosinophilic Granulomatosis with Polyangiitis (EGPA)
Has the recipient’s disease relapsed or is it refractory to standard of care therapy (i.e., corticosteroid treatment with or
without immunosuppressive therapy)?
Yes
No
Is the recipient currently receiving corticosteroid therapy?
Yes
No
Is the medication prescribed by or in consultation with a pulmonologist, rheumatologist, or allergist/immunologist?
Yes
No
Is the request for recertification of Nucala®?
Yes
No
If yes, is there documentation of a positive clinical response to Nucala® therapy (e.g., increase in remission time)?
Yes
No
Other diagnosis: ________________________________ ICD-10 Code(s): _________________________________
Xolair® (omalizumab)
Please select the recipient’s diagnosis below and answer the following diagnosis-related questions:
Moderate to Severe Persistent Asthma
Will the recipient use the requested antiasthmatic monoclonal antibody in combination with other antiasthmatic
monoclonal antibodies?
Yes
No
Is the recipient 6 years of age or older?
Yes
No
(Xolair® (omalizumab) criteria continued on next page)
FA-83 08/03/2020
Page 3 of 4
Xolair® (omalizumab) continued
Does the recipient have a history of a positive skin test or Radioallergosorbent (RAST) test to a perennial
aeroallergen?
Yes
No
Is the medication prescribed by a pulmonologist or allergist/immunologist?
Yes
No
Has the recipient had an inadequate response, adverse reaction or contraindication to inhaled, oral corticosteroids?
Yes, drug/response: _________________________________________________________________
No
Has the recipient had an inadequate response, adverse reaction or contraindication to a leukotriene receptor
antagonist?
Yes, drug/response: ______________________________________________________
No
Please record the recipient’s pretreatment serum total Immunoglobulin E (IgE) level: __________________________
Please record the recipient’s current weight: __________________________
Please record the requested dose: _______________ mg every ______ weeks
Chronic Idiopathic Urticaria (CIU)
Will the recipient use the requested antiasthmatic monoclonal antibody in combination with other antiasthmatic
monoclonal antibodies?
Yes
No
Is the recipient 12 years of age or older?
Yes
No
Has the recipient had an inadequate response, adverse reaction or contraindication to two different oral second-
generation antihistamines?
Yes, drug names: ________________________________________________
No
Has the recipient had an inadequate response, adverse reaction or contraindication to an oral second-generation
antihistamine in combination with a leukotriene receptor antagonist?
Yes, drug names: _____________________________________________________
No
Is the medication prescribed by a dermatologist, rheumatologist, or allergist/immunologist?
Yes
No
If no, is there documentation in the recipient’s medical record that a consultation was done by an
allergist/immunologist, dermatologist or a rheumatologist regarding the diagnosis and treatment
recommendations?
Yes (attach documentation)
No
Select the requested dose from the following:
Initial therapy: 150 mg every four weeks
Initial therapy: 300 mg every four weeks (Please provide clinical rationale for starting therapy at this
dose: ____________________________________________________________________________________)
Continuation of therapy: 150 mg every four weeks
Continuation of therapy: 300 mg every four weeks
Other: _____________________________________
Other diagnosis: ________________________________ ICD-10 Code(s): _________________________________
*Please attach all supporting documentation to request*
Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any 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-83 08/03/2020
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