FAX Completed Form To - PDF Document

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  1. FAX Completed Form To 1.877.386.4695 Provider Help Desk 1.866.399.0928 Request for Prior Authorization TOPICAL ACNE AND ROSACEA PRODUCTS (PLEASE PRINT – ACCURACY IS IMPORTANT) Patient name IA Medicaid Member ID # DOB Patient address Provider NPI Prescriber name Phone Prescriber address Fax Pharmacy name Address Phone Prescriber must complete all information above. It must be legible, correct, and complete or form will be returned. Pharmacy NPI Pharmacy fax NDC Prior authorization is required for topical acne agents (topical antibiotics and topical retinoids) and topical rosacea agents. Payment for topical acne and topical rosacea agents will be considered under the following conditions: 1) Documentation of diagnosis. 2) For the treatment of acne vulgaris, benzoyl peroxide is required for use with a topical antibiotic or topical retinoid. 3) Payment for non-preferred topical acne products will be authorized only for cases in which there is documentation of previous trials and therapy failures with two preferred topical acne agents of a different chemical entity from the requested topical class (topical antibiotic or topical retinoid). 4) Payment for non-preferred topical rosacea products will be authorized only for cases in which there is documentation of a previous trial and therapy failure with a preferred topical rosacea agent. 5) Requests for non-preferred combination products may only be considered after documented trials and therapy failures with two preferred combination products. 6) Requests for topical retinoid products for skin cancer, lamellar ichthyosis, and Darier’s disease diagnoses will receive approval with documentation of submitted diagnosis. 7) Trial and therapy failure with a preferred topical antipsoriatic agent will not be required for the preferred tazarotene (Tazorac) product for a psoriasis diagnosis. 8) Duplicate therapy with agents in the same topical class (topical antibiotic or topical retinoid) will not be considered. The required trials may be overridden when documented evidence is provided that the use of these agents would be medically contraindicated. Preferred Non-Preferred Acanya Adapalene Gel Azelex Clindamycin Differin Epiduo Erythromycin MetroGel 1% MetroLotion Metronidazole 0.75% Cream Retin-A Tazorac Aczone Adapalene/Benzoyl Peroxide Adapalene Cream/Lotion/Sol Altreno Lotion Atralin Azelaic Acid Gel 15% BenzaClin Benzamycin Benzamycin Pak Cleocin T Clindamycin/BPO Clindamycin Phosphate-Tretinoin Duac Erythromycin/BPO Fabior Finacea Klaron MetroCream Metronidazole Gel & Lotion Other (specify) Noritate Onexton Plixda Pads Retin-A Micro Sodium Sulfa/Sulf Soolanta Tretinoin Ziana Strength Dosage Form Dosage Instructions Quantity Days Supply Diagnosis: 1 of 2 Rev. 6/19

  2. FAX Completed Form To 1.877.386.4695 Request for Prior Authorization TOPICAL ACNE AND ROSACEA PRODUCTS (PLEASE PRINT – ACCURACY IS IMPORTANT) Provider Help Desk 1.866.399.0928 If acne vulgaris, document concurrent benzoyl peroxide use: Drug Name & Strength: Dosing Instructions: Start date: Non-Preferred Topical Acne or Rosacea Products Acne Diagnosis: Document trials with two preferred topical acne agents of a different chemical entity; if a non- preferred combination product is requested, the two trials must be preferred topical acne combination products Rosacea diagnosis: Document trial with one preferred topical rosacea agent of a different chemical entity: Preferred Trial 1: Name/Dose: Trial Dates: Failure reason: Preferred Trial 2: Name/Dose: Trial Dates: Failure reason: Medical or contraindication reason to override trial requirements: Other relevant information: Possible drug interactions/conflicting drug therapies: Attach lab results and other documentation as necessary. Prescriber signature (Must match prescriber listed above.) Date of submission IMPORTANT NOTE: In evaluating requests for prior authorization the consultant will consider the treatment from the standpoint of medical necessity only. If approval of this request is granted, this does not indicate that the member continues to be eligible for Medicaid. It is the responsibility of the provider who initiates the request for prior authorization to establish by inspection of the member’s Medicaid eligibility card and, if necessary by contact with the county Department of Human Services, that the member continues to be eligible for Medicaid. 2 of 2 Rev. 6/19