Form FA-86 "Prior Authorization Request - Marinol (Dronabinol)" - Nevada

What Is Form FA-86?

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 May 11, 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-86 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form FA-86 "Prior Authorization Request - Marinol (Dronabinol)" - Nevada

Download PDF

Fill PDF online

Rate (4.8 / 5) 63 votes
Prior Authorization Request
Nevada Medicaid – OptumRx
®
Marinol
(dronabinol)
Submit fax request to: 855-455-3303
®
Purpose: For a prescribing physician to request prior authorization for Marinol
(dronabinol)
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
Applicable ICD-10 code and diagnosis or symptom/side effect (REQUIRED):
Name:
Strength:
Generic substitution not permitted
Dosage:
Duration:
CLINICAL INFORMATION
The following criteria must be met and documented in the recipient’s medical record.
Check the applicable boxes to indicate each item as true for the recipient:
The recipient has a diagnosis of chemotherapy-induced nausea/vomiting
The recipient has a diagnosis of AIDS-related anorexia associated with weight loss
The recipient has experienced an inadequate response, adverse event, or has a contraindication to at least one
serotonin receptor antagonist (please document below)
The recipient has experienced an inadequate response, adverse event or has a contraindication to at least one other
antiemetic agent (please document below)
The recipient has experienced an inadequate response, adverse event or has a contraindication to megestrol
®
(Megace
) (please document below)
®
The prescriber is aware of the potential for mental status changes associated with the use of Marinol
(dronabinol)
and will closely monitor the recipient
®
For requests for brand name Marinol
(dronabinol)
The recipient has experienced an inadequate response, adverse event or has a contraindication to generic formulation
of the requested medication (please document below)
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 is 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:
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-86
05/11/2017 pv12/02/2013
Page 1 of 1
Prior Authorization Request
Nevada Medicaid – OptumRx
®
Marinol
(dronabinol)
Submit fax request to: 855-455-3303
®
Purpose: For a prescribing physician to request prior authorization for Marinol
(dronabinol)
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
Applicable ICD-10 code and diagnosis or symptom/side effect (REQUIRED):
Name:
Strength:
Generic substitution not permitted
Dosage:
Duration:
CLINICAL INFORMATION
The following criteria must be met and documented in the recipient’s medical record.
Check the applicable boxes to indicate each item as true for the recipient:
The recipient has a diagnosis of chemotherapy-induced nausea/vomiting
The recipient has a diagnosis of AIDS-related anorexia associated with weight loss
The recipient has experienced an inadequate response, adverse event, or has a contraindication to at least one
serotonin receptor antagonist (please document below)
The recipient has experienced an inadequate response, adverse event or has a contraindication to at least one other
antiemetic agent (please document below)
The recipient has experienced an inadequate response, adverse event or has a contraindication to megestrol
®
(Megace
) (please document below)
®
The prescriber is aware of the potential for mental status changes associated with the use of Marinol
(dronabinol)
and will closely monitor the recipient
®
For requests for brand name Marinol
(dronabinol)
The recipient has experienced an inadequate response, adverse event or has a contraindication to generic formulation
of the requested medication (please document below)
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 is 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:
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-86
05/11/2017 pv12/02/2013
Page 1 of 1