Topical Acne Rosacea Products Prior Authorization of Benefits Form - PDF Document

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  1. Topical Acne Rosacea Products Prior Authorization of Benefits Form CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete form in its entirety and fax to: Prior Authorization of Benefits Center at 1-844-512-9004. Provider Help Desk: 1-800-454-3730 1. Patient information 2. Physician information Patient name: ___________________________________ Prescribing physician: __________________________ Patient ID #: ____________________________________ Physician address: _____________________________ Patient DOB: ____________________________________ Physician phone #: ____________________________ Date of Rx: _____________________________________ Physician fax #: _______________________________ Patient phone #: _________________________________ Physician specialty: ____________________________ Patient email address: ____________________________ Physician DEA: _______________________________ Physician NPI #: _______________________________ Physician email address: ________________________ 3. Medication 4. Strength 5. Directions 6. Quantity per 30 days Specify: 7. Diagnosis: ___________________________________________________________________________________ 8. Approval criteria: Check all boxes that apply. Note: Any areas not filled out are considered not applicable to your patient and may affect the outcome of this request. 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 nonpreferred 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 nonpreferred 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 nonpreferred 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. https://providers.amerigroup.com/IA IAPEC-1922-20 April 2020

  2. The required trials may be overridden when documented evidence is provided that the use of these agents would be medically contraindicated. Preferred: Nonpreferred: ☐ Acanya ☐ Erythromycin ☐ Aczone ☐ Finacea ☐ Adapalene gel ☐ MetroGel 1 percent ☐ Klaron ☐ Metro cream ☐ Adapalene/benzoyl peroxide ☐ MetroLotion ☐ Adapalene cream/lotion/sol ☐ Metronidazole gel and lotion ☐ Azelex ☐ Metronidazole ☐ Altreno lotion ☐ Noritate ☐ Clindamycin 0.75 percent cream ☐ Altralin ☐ Differin ☐ Retin-A ☐ Azelaic acid gel 15 percent ☐ Plixda pads ☐ Epiduo ☐ Tazorac ☐ BenzaClin ☐ Retin-A micro ☐ Benzamycin ☐ Sodium sulfa/sulf ☐ Benzamyci pak ☐ Soolanta ☐ Cleocin T ☐ Clindamycin/BPO ☐ Clindamycin phosphate-tetinoin ☐ Fabior ☐ Duac ☐ Erythromycin/BPO If acne vulgaris, document concurrent benzoyl peroxide use: Drug name and strength: Dosing instructions: Start date: Nonpreferred topical acne or rosacea products Acne diagnosis: Document trials with two preferred topical acne agents of a different chemical entity; if a nonpreferred 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. ☐ Onexton ☐ Tretinoin ☐ Ziana ☐Other (specify): ________________________ Page 2 of 3

  3. 9. Physician signature Prescriber or authorized signature Date Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient. _________________________________ Note: Payment is subject to member eligibility. Authorization does not guarantee payment. Page 3 of 3