Form FA-82 "Prior Authorization Request - Stelara (Ustekinumab)" - Nevada

What Is Form FA-82?

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 23, 2017;
  • 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 fillable version of Form FA-82 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-82 "Prior Authorization Request - Stelara (Ustekinumab)" - Nevada

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Prior Authorization Request
Nevada Medicaid – OptumRx
Stelara
®
(ustekinumab)
Submit fax request to: 855-455-3303
Purpose: For a prescribing physician to request prior authorization for Stelara
®
(ustekinumab).*
Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.
DATE OF REQUEST:
RECIPIENT INFORMATION
Last Name, First Name, Middle Initial:
Date of Birth:
Recipient ID:
Gender:
Male
Female
Phone:
PRESCRIBING PROVIDER INFORMATION
Name:
NPI:
Specialty:
Phone:
Fax (required):
Person to contact regarding this request:
DIAGNOSIS AND REQUESTED DRUG
Name: Stelara
Strength:
Dosage:
Duration:
Please document the recipient’s diagnosis:
Plaque Psoriasis
The recipient has failed to adequately respond to a topical agent.
Other:_____________________________________
CLINICAL INFORMATION
Check the applicable boxes to indicate each item as true for the recipient:
The recipient has mild disease activity.
The recipient has moderate disease activity.
The recipient has high/severe disease activity.
The recipient does not have an active infection or history of recurring infections.
The recipient has had a negative tuberculin test prior to initiating requested treatment.
The recipient has had a positive tuberculin test prior to initiating requested treatment.
Treatment with isoniazid was initiated ≥1 month prior to initiating requested treatment (only if test was positive).
The recipient has an allergy, history of unacceptable/toxic side effects, drug-drug interaction or therapeutic failure with
®
®
®
Cimzia
, Enbrel
and Humira
(if indicated for diagnosis). Please document:__________________________________
®
Stelara
is being requested for a unique indication that is supported by peer-reviewed literature or a unique FDA-
approved indication (document diagnosis above).
List the medications that were tried and failed for the given diagnosis:
Drug Name
Reason for Failure
Date(s)
__________________________
__________________________________
_____________________
__________________________
__________________________________
_____________________
Additional clinical information (if applicable):
– Prescriber’s signature and date required.
PROVIDER CERTIFICATION
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined
by Nevada Medicaid.
Prescriber’s Signature:
Date:
* Authorization will not be given for the use of more than one biologic at a time (combination therapy).
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions,
coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is
privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the
employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this
communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.
FA-82
08/23/2017 pv12/02/2013
Page 1 of 1
Prior Authorization Request
Nevada Medicaid – OptumRx
Stelara
®
(ustekinumab)
Submit fax request to: 855-455-3303
Purpose: For a prescribing physician to request prior authorization for Stelara
®
(ustekinumab).*
Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.
DATE OF REQUEST:
RECIPIENT INFORMATION
Last Name, First Name, Middle Initial:
Date of Birth:
Recipient ID:
Gender:
Male
Female
Phone:
PRESCRIBING PROVIDER INFORMATION
Name:
NPI:
Specialty:
Phone:
Fax (required):
Person to contact regarding this request:
DIAGNOSIS AND REQUESTED DRUG
Name: Stelara
Strength:
Dosage:
Duration:
Please document the recipient’s diagnosis:
Plaque Psoriasis
The recipient has failed to adequately respond to a topical agent.
Other:_____________________________________
CLINICAL INFORMATION
Check the applicable boxes to indicate each item as true for the recipient:
The recipient has mild disease activity.
The recipient has moderate disease activity.
The recipient has high/severe disease activity.
The recipient does not have an active infection or history of recurring infections.
The recipient has had a negative tuberculin test prior to initiating requested treatment.
The recipient has had a positive tuberculin test prior to initiating requested treatment.
Treatment with isoniazid was initiated ≥1 month prior to initiating requested treatment (only if test was positive).
The recipient has an allergy, history of unacceptable/toxic side effects, drug-drug interaction or therapeutic failure with
®
®
®
Cimzia
, Enbrel
and Humira
(if indicated for diagnosis). Please document:__________________________________
®
Stelara
is being requested for a unique indication that is supported by peer-reviewed literature or a unique FDA-
approved indication (document diagnosis above).
List the medications that were tried and failed for the given diagnosis:
Drug Name
Reason for Failure
Date(s)
__________________________
__________________________________
_____________________
__________________________
__________________________________
_____________________
Additional clinical information (if applicable):
– Prescriber’s signature and date required.
PROVIDER CERTIFICATION
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined
by Nevada Medicaid.
Prescriber’s Signature:
Date:
* Authorization will not be given for the use of more than one biologic at a time (combination therapy).
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions,
coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is
privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the
employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this
communication is strictly prohibited. If this communication is received in error, the reader shall notify sender immediately and destroy all information received.
FA-82
08/23/2017 pv12/02/2013
Page 1 of 1