Prior Authorization Criteria Form

Prior Authorization FCHP - (MEDICAID) Compounded Drug Products (FCHP) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Fallon Health at 1-855-762-5204. Please contact Fallon Health at 1-866-643-5126 with questions regarding the Prior Authorization process. When conditions are met, we will authorize the coverage of Compounded Drug Products (FCHP) . Drug Name (select from list of drugs shown) Other, Please specify Quantity Frequency Strength Route of Administration Expected Length of Therapy Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Patient Phone: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: ICD Code: Comments: Please circle the appropriate answer for each question. 1. Is the request for a compounded bio-identical hormone Y N product for hormone replacement therapy? 2. Is this request for a compound that is being used for Y N cosmetic use, medical (wound) dressing, topical emollient, anti-aging, or convenience? 3. Does the requested compound contain any of the following Y N ingredients: A) Androstanolone Powder, B) Androstenediol (Bulk) Powder, C) Androstenedione (Bulk) Powder, D) Androsterone (Bulk) Powder, E) Dienestrol (Bulk) Powder, F) Dihydrotestosterone Propionate Powder, G) Epitestosterone (Bulk) Powder, H) Estradiol Benzoate (Bulk) Powder, I) Estradiol Cypionate (Bulk) Powder, J) Estradiol Micronized Powder, K) Estradiol Powder, L) Estradiol Valerate (Bulk) Powder, M) Estriol Micronized Powder, N) Estrogens, Conjugated Powder, O) Estrone Crystals, P) Estrone Powder, Q) Estropipate (Bulk) Powder, R) Ethinyl Estradiol Powder, S) Hydroxyprogesterone Caproate (Bulk) Powder, T) Medroxyprogesterone Acetate Micronized (Bulk) Powder, U) Medroxyprogesterone Micronized Powder, V) Methyltestosterone Powder, W) Norethindrone (Bulk) Powder, X) Norethindrone Acetate Powder, Y) Progesterone Micronized Powder (excluding progesterone suppositories), Z) Progesterone Powder (excluding progesterone suppositories), AA) Testosterone Cypionate Powder, BB) Testosterone Decanoate (Bulk) Powder, CC) Testosterone Enanthate (Bulk) Powder, DD) Testosterone Isocaproate (Bulk) Powder, EE) Testosterone Phenylpropionate (Bulk) Powder, FF) Testosterone Powder, GG) Testosterone Propionate Powder? 4. Is the request for a compound of an oral liquid formulation Y N of a solid dosage form? [If no, then skip to question 6.] 5. Are all of the following conditions true for the compounded Y N oral liquid formulation: A) contains only 1 prescription product, B) may or may not also contain OTC products, C) patient is unable to take the solid dosage form or there is no corresponding dose available in the solid dosage form, D) a commercially available liquid formulation of the product in the same strength is NOT available? [No further questions.] 6. Is each active ingredient in the compound an FDA- Y N approved drug? 7. Is each active ingredient in the compound being used for Y N an indication that is FDA-approved or compendia supported? 8. Does the requested compound contain at least one Y N prescription medication which is not otherwise excluded from coverage? 9. Does the patient have a clinical contraindication to any Y N component of the requested product? 10. Is the requested compound being prescribed for purposes Y N that are medically necessary? 11. Is the route of administration of the compound the same Y N as the FDA-approved or compendial supported route of administration for each active ingredient? 12. Is the dosing within guidelines for each active ingredient? Y N 13. Is there evidence in the compendia of current literature Y N (e.g., AHFS, Micromedex, current accepted guidelines, etc.) that show the safety, efficacy, and improvement in net health outcomes concerning this compound therapy when compared to existing therapy for the medical condition being treated? [Note: Articles must be submitted with PA request.] 14. Is at least ONE of the following criteria met: A) There is a Y N current supply shortage of the commercial product, B) The patient has a medical need for a dosage form or strength that is not commercially available, C) The patient had a trial and intolerance or contraindication to the commercially available product, D) The commercially available product has been discontinued by the manufacturer for reasons other than lack of safety or effectiveness? 15. Are there FDA-approved therapies or other standard Y N therapies for the medical condition being treated? [If no, then skip to question 17.] 16. Has the patient demonstrated a trial and failure of or Y N contraindication to the FDA-approved therapies or other standard therapies for the medical condition being treated? [Note: Medication usage must be documented in patient's medical records.] 17. Is the request for a topical compound (i.e., cream, gel, Y N lotion, ointment, solution)? [If no, then skip to question 19.] 18. Does the compound include bulk powders OR any Y N ingredient that is not FDA approved for topical use OR any of the following ingredients: A) Amitriptyline, B) Baclofen, C) Cholestyramine, D) Cyclobenzaprine, E) Dexamethasone (except ophthalmic solution), F) Flurbiprofen (except ophthalmic solution), G) Fluticasone propionate, H) Gabapentin, I) Hyaluronate (except ophthalmic solution), J) Itraconazole, K) Ketamine, L) Ketoprofen, M) Ketorolac (except ophthalmic solution), N) Lamotrigine, O) Meloxicam, P) Penlac, Q) Sumatriptan, R) Tramadol? [No further questions.] 19. Is the request for vancomycin? Y N [If no, then no further questions.] 20. Is the request for an oral vancomycin compound, and is it Y N being compounded from vancomycin injectable? I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature and Date .

Load more