Medical Benefit Drugs Prior Authorization Request Form

Medical Benefits Drugs Medicare Advantage Prior Authorization Request Form — Fax: 866-874-0857

Instructions: This form is to be used by participating providers to request authorization for medical benefit drugs: Aloxi® (palonosetron HCI injection), Anzemet® (dolasetron mesylate injection), Emend® (fosaprepitant dimeglumine injection), Entyvio® (vedolizumab), Eylea® (aflibercept injection), IVIG® (intravenous immunoglobulin), Lucentis® (ranibizumab injection), Ocrevus® (ocrelizumab), Onpattro® (patrisiran injection), Remicade (infliximab), Rituxan (rituximab), Stelara (ustekinumab) and Tysabri® (natalizumab). For any oncology related indications, antiemetics (Aloxi, Anemet & Emend) request prior authorization through the Oncology Analytics program. Please refer to Oncology Analytics for medical necessity and criteria www.oncologyanalytics.com/terms/#criteria.

If you have any questions about this process, please contact the Medicare Advantage Provider Service Center at 888-609-0692. ONLY COMPLETED FORMS CAN BE PROCESSED Harvard Pilgrim reserves the right to request additional clinical information. Incomplete forms or lack of supporting documentation may delay response time. Please check the box below only if request meets the definition of "expedited." Expedited: Medicare defines expedited requests as those where “applying the standard time for making a determination could seriously jeopardize the enrollee’s health, life, or ability to regain maximum function.”

Patient Information Person Completing Form Patient name: Name:

HPHC member ID #: Phone #:

Date of birth: Fax #:

Requesting Provider/Facility Servicing Provider/Facility Last name: Last name: First name: First name: Title (NP, PA): Title (NP, PA): HPHC provider ID #: Address:

NPI #:

Date of service: HPHC provider ID # (if known)

Diagnosis: Tax ID #:

ICD-10 code:

Service type: Inpatient Outpatient Number of visits/units requested: Observation Other

Service start date: Authorization type: Service end date:

(Continued) Harvard Pilgrim Health Care—StrideSM Medicare Advantage Provider Manual 15 July 2021 MEDICARE ADVANTAGE PRIOR AUTHORIZATION REQUEST FORM (CON'T) Medical Benefit Drugs

Procedure code(s)

Requested medication: Aloxi® (palonosetron HCI injection) Ocrevus® (ocrelizumab) Anzemet® (dolasetron mesylate injection) Onpattro® (patrisiran injection) Emend® (fosaprepitant dimeglumine injection) Remicade (infliximab) Entyvio® (vedolizumab) Rituxan (rituximab) Eylea® (aflibercept injection) Stelara (ustekinumab IVIG® (intravenous immunoglobulin) Tysabri® (natalizumab) Lucentis® (ranibizumab injection)

New Start (Drug Naive) Dosage requested: Ongoing treatment/Reauthorization • Date of initial therapy Frequency (weekly, monthly, etc.):

Pertinent History Member’s Height (in/CM) ______Weight (lb/kg)______Please attach other pertinent information to support the request for this medication, other medications tried, names of medications, length and response to treatment.

Other therapies tried (as applicable for initial drug request — please see specific policy for criteria).

Name of Drug Duration (date & length) Outcome, including intolerance & adverse reactions

Reauthorization/ongoing Treatment (as applicable for ongoing treatment request – please see specific policy for criteria).

Reauthorization request must include evidence of symptom improvement(s) per applicable policy criteria: ______

Harvard Pilgrim Health Care—StrideSM Medicare Advantage Provider Manual 16 July 2021