sign in sign up
<<
Home , Asenapine

Medications Prior Authorization of Benefits Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete form in its entirety and fax to: Prior Authorization of Benefits Center at 844-512-9005 for retail pharmacy or 844-512-7027 for medical injectable.

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.)

For all requests, please answer the following: □ Yes □ No Is the patient maintained on a stable dose of the requested medication? □ Yes □ No Is the requested medication being prescribed for a pediatric patient (age 17 years and younger)?

If the request is for Latuda (), please also answer the following questions: What is the diagnosis or reason for treatment? □ Bipolar depression □ Other diagnosis that is not listed above (specify): ______□ Yes □ No Does the patient have significant cardiovascular risk factors (such as a high risk of QTc prolongation)? □ Yes □ No Is the patient at high risk for complications related to weight gain?

www.HealthyBlueSC.com BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC. an independent company, for services to support administration of Healthy Connections. To report fraud, call our confidential Fraud Hotline at 877-725-2702. You may also call the South Carolina Department of Health and Human Services Fraud Hotline at 888-364-3224 or email [email protected]. BSCPEC-1019-18 September 2018 Healthy Blue Antipsychotic Medications Prior Authorization of Benefits Form Page 2 of 3

Patient name: ______Patient ID #: ______

If the request is for Seroquel XR, XR (brand and generic), please also answer the following questions: What is the diagnosis or reason for treatment? □ Major depressive disorder □ Other diagnosis that is not listed above (specify): ______□ Yes □ No Does the patient use concomitant therapy?

If the request is for a nonpreferred medication — [Abilify Mycite ( with sensor); aripiprazole ODT/solution; Fanapt (); Latuda (lurasidone); ODT; risperidone oral syringe; Saphris (asenapine); Seroquel XR, quetiapine XR (brand and generic); Symbyax, / (brand and generic); or Vraylar ()] — please also answer the following questions: □ Yes □ No The requested medication is Abilify Mycite, and the prescriber has confirmed clinical necessity to track medication ingestion. □ Yes □ No Has the patient had a trial and inadequate response or intolerance to one preferred generic oral medication?* □ Yes □ No Is the following statement true for this patient: The preferred generics are not FDA-approved and do not have an accepted off-label use, per the off-label policy for the prescribed indication, but the nonpreferred medication does.* * Please note: Preferred generic oral medications are: aripiprazole tablet, olanzapine, , quetiapine, risperidone tablet/solution and .

For pediatric patients (age 17 years and younger), please also answer the following questions: Does the patient have a psychiatric diagnosis that is amenable to treatment with an antipsychotic agent including but not limited to one of the following conditions? [Please note: Select the option below that best applies to this patient's condition.] □ Patient has . □ Patient has , and the requested medication is one of the following: Seroquel (quetiapine), Risperdal (risperidone), Zyprexa (olanzapine), Geodon (ziprasidone), Seroquel XR (quetiapine), Saphris (asenapine), Latuda (lurasidone), Vraylar (cariprazine), or Abilify (aripiprazole). [Please note: Includes all Abilify formulations.] □ Patient has irritability associated with autism, and the requested medication is one of the following: Risperdal (risperidone) or Abilify (aripiprazole). [Please note: Does not include Abilify Mycite formulation.] □ Patient has severe behavioral problems including explosive hyperexcitability, which cannot be accounted for by immediate provocation, and the requested medication is one of the following: chlorpromazine or . □ None of the above options applies to this patient. □ Yes □ No Does the patient have one of the following: patient has utilized nondrug treatment measures such as psychosocial intervention/care in the previous 12 months; patient has had an acute inpatient visit for a diagnosis of schizophrenia, bipolar disorder or other psychotic disorder in the previous 12 months; or patient has had at least two visits in outpatient, intensive outpatient or partial hospitalization setting for a diagnosis of schizophrenia, bipolar disorder or other psychotic disorder in the previous 12 months? □ Yes □ No Is the prescriber regularly monitoring the patient for metabolic side effects (such as obtaining blood glucose or hemoglobin A1C [HbA1c], total cholesterol or LDL-C, or reviewing BMI changes)?

Healthy Blue Antipsychotic Medications Prior Authorization of Benefits Form Page 3 of 3

Patient name: ______Patient ID #: ______

Pediatric patients (continued) □ Yes □ No Is the prescriber regularly monitoring for neurological side effects (such as evaluation of movement disorders using tools including Abnormal Involuntary Movement Scale and the Neurological Rating Scale)? □ Yes □ No Is the requested medication being prescribed by a psychiatrist, neurologist or developmental/behavioral pediatrician? □ Yes □ No Has the prescriber consulted with a psychiatrist, neurologist or developmental/behavioral pediatrician? □ Yes □ No Does the prescriber have timely access to a psychiatrist, neurologist or developmental/behavioral pediatrician?

Is the patient requesting an antipsychotic agent to treat one of the following conditions? [Please note: Select the option below that best applies to this patient's condition.] □ Patient has nausea and vomiting, and the requested medication is one of the following: chlorpromazine, or . □ Patient has Tourette's disorder/tic disorder, and the requested medication is one of the following: Orap (), haloperidol or Abilify (aripiprazole). [Please note: Does not include Abilify Mycite formulation.] □ Patient has presurgical apprehension, and the requested medication is chlorpromazine. □ None of the above options applies to this patient. □ Yes □ No Does a therapeutic alternative exist? □ Yes □ No Was a previous trial of a therapeutic alternative ineffective for this patient?

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.

THIS MESSAGE IS INTENDED ONLY FOR THE USE OF THE MEDICAL PROVIDER TO WHOM IT IS ADDRESSED AND MAY CONTAIN HEALTH INFORMATION THAT IS PROTECTED BY LAW. If this transmission contains the protected health information of an individual who is unknown to your practice, please notify us immediately by calling 866-757-8286. Please be advised that copying, sharing or any further use or disclosure of this communication is strictly prohibited.