HMSA ASO Topical Antifungals Jublia (Efinaconazole) Kerydin (Tavaborole

HMSA ASO Topical Antifungals Jublia (Efinaconazole) Kerydin (Tavaborole

PA Request Criteria HMSA ASO Topical Antifungals This fax machine is located in a secure location as required by HIPAA regulations. Fax complete signed and dated forms to CVS/Caremark at 855-762-5207. Please contact CVS/Caremark at 855-240-0543 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Topical Antifungals. Patient Information Patient Name: Patient Phone: - - Patient ID: Patient Group No: Patient DOB: / / Prescribing Physician Physician Name: Physician - - Phone: Physician Fax: - - Physician Address: City, State, Zip: Drug Name (select from list of drugs shown) Jublia (efinaconazole) Kerydin (tavaborole) Oxiconazole Cream Oxistat Cream (oxiconazole) Quantity: ____________ Frequency: __________________ Strength: __________________ Route of Administration: _______________________ Expected Length of Therapy: _____________________ Diagnosis: ICD Code: __________________________________ Comments: _____________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Please check the appropriate answer for each applicable question. 1. Is this a request for oxiconazole cream (Oxistat)? Y N 2. Is the requested drug being prescribed for any of the following: A) tinea corporis, B) tinea Y N cruris, C) tinea pedis, D) tinea versicolor? 3. Is the drug being prescribed for onychomycosis of the toenail(s) due to Trichophyton Y N rubrum and Trichophyton mentagrophytes? 4. Has the diagnosis been confirmed with a fungal diagnostic test (e.g., KOH preparation, Y N fungal culture, or nail biopsy)? I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that the documentation supporting this information is available for review if requested by the claims processor, the health plan sponsor, or, if applicable a state or federal regulatory agency. _____________________________________________________________________ Prescriber (Or Authorized) Signature and Date Now you can get responses to drug PAs immediately and securely online—without faxes, phone calls, or waiting. How? With electronic prior authorization (ePA)! For more information and to register, go to www.caremark.com/epa..

View Full Text

Details

  • File Type
    pdf
  • Upload Time
    -
  • Content Languages
    English
  • Upload User
    Anonymous/Not logged-in
  • File Pages
    1 Page
  • File Size
    -

Download

Channel Download Status
Express Download Enable

Copyright

We respect the copyrights and intellectual property rights of all users. All uploaded documents are either original works of the uploader or authorized works of the rightful owners.

  • Not to be reproduced or distributed without explicit permission.
  • Not used for commercial purposes outside of approved use cases.
  • Not used to infringe on the rights of the original creators.
  • If you believe any content infringes your copyright, please contact us immediately.

Support

For help with questions, suggestions, or problems, please contact us