High Risk Medication Coverage Determination Mail requests to: Coverage Determination & Exceptions PO Box 20002 Nashville, TN 37202 Fax requests to: (866) 845-7267 Request by phone: (877) 813-5595 FOR PROVIDER USE ONLY Office Contact: Provider Specialty: Provider First Name: Provider Last Name: Provider Phone: Provider Fax: Provider Address: License Number: DEA Number: NPI Number: Customer Name: Customer Address: Customer Phone:(H) (C) Customer ID: DOB: Rx Prescription Information Drug: Dosage: Frequency: Quantity: □ Brand □ Generic □ New Medication □ Continuation (Provide Start Date) Refills: Indication for High Risk Medication (HRM): Use of high risk medications is a safety concern in patients over the age of 64 and should be avoided in the elderly if possible. The physician has documented that the patient has tried and failed two (2) safer formulary alternatives (see page 3 for the list ) if two are available If only one (1) alternative is available, then only that particular medication would need to be documented as tried and failed: Does beneift outweight the potential risk associated with this medication? If so, provide a detailed explanation of the Does benefit outweight the potential risk associated with this medication? If so, provide a detailed explanation of the specific benefit established and how the benefit outweighs the potential risk: Please provide specific detail on the ongoing monitoring plan for the high risk medication requested: HRM_Form INT_14_23260 1 Rev 072215 Request for expedited review [24 hours]. By checking this box, I certify that applying the 72 hour standard review time frame may seriously jeopardize the life or health of the Customer or the Customer's ability to regain maximum function. Provider Signature: Date: All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. HRM_Form INT_14_23260 2 Rev 072215 High Risk Medication Safer Formulary Alternatives (does not apply to PDP EGWP/AZ MAPD plans) Depression: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Citalopram, Amitriptyline, Amitriptyline- Venlafaxine, Fluoxetine, Paroxetine, Sertraline, Duloxetine, and Bupropion Chlordiaxepoxide, Headache Prophylaxis: Propranolol, Topiramate, Divalproex sodium Amitriptyline-Perphenazine Headhache Treatment: Sumatriptan, Naratriptan, Dihydroergotamine Pain/Neuropathy: Duloxetine, Lyrica, Gabapentin Parkinsonism: Carbidopa/Levodopa, Pramipexole, Ropinirole, Bromocriptine, Benztropine Mesylate Amantadine, and Selegiline EPS: Amantadine Butalbital combinations Tension headaches: Naproxen Migraine: Off-label For Spasticity: Baclofen, Tizanidine tabs; For Musculoskeletal Pain: Oral NSAIDs, Chlorzoxazone Voltaren gel, and Duloxetine Clomipramine Citalopram, Paroxetine, Fluoxetine, and Sertraline Muscle Spasticity: Baclofen, Tizanidine Cyclobenzaprine Fibromyalgia/Pain: Voltaren gel (requires ST), Oral NSAIDs, Duloxetine, Lyrica and Gabapentin Digoxin 250 mcg 0.125 mcg daily Depression: Nortriptyline, Protriptyline, Desipramine, Amoxapine, Venlafaxine, Doxepin Citalopram, Paroxetine, Fluoxetine, Sertraline, duloxetine, Bupropion Sleep (off label for generic): Rozerem and Silenor Ergoloid mesylates Donepezil, galantamine and rivastigmine Estrogens (including esterified and Hot Flashes: Estradiol Valerate and Depo-Estradiol combinations, conjugated, Vaginal Symptoms: Premarin Cream, Estring, and Femring estradiol, estropipate, premarin, Bone Density: Alendronate, Raloxifene, and Prolia (requires ST) etc) Glyburide-Metformin Glipizide-Metformin For Depression/Anxiety: Nortriptyline, Protriptyline, Desipramine, Amoxapine, SSRIs Imipramine (Fluoxetine, Citalopram, Paroxetine, Sertraline), Venlafaxine, Duloxetine, Bupropion; For neuropathic pain: Gabapentin, Duloxetine, and Lyrica Megestrol Dronabinol (requires PA) ACE inhibitors: (Benazepril, Captopril, Enalapril, Lisinopril, Quinapril, and Ramipril), ARBs: (Candesartan, Irbesartan, Losartan, and Telmisartan), Beta-blockers: Methyldopate (Atenolol, Metoprolol, Nadolol, Pindolol, and Propranolol), Calcium channel blockers: (Verapamil, Diltiazem, Amlodipine, Felodipine, and Nifedipine ER), Thiazide diuretics: (Hydrochlorothiazide, Chorthalidone, and Indapamide) Orphenadrine (including For Spasticity: Baclofen, Tizanidine tabs; For Musculoskeletal Pain: Oral NSAIDs, combinations) Voltaren gel, and Duloxetine For nausea and vomiting: Ondansetron (QL = 90/30); For allergic conditions: Promethazine Levocetirizine, Desloratadine Risperidone, Quetiapine, Abilify (requires ST), Olanzapine, Saphris (requires ST), and Thioridazine Ziprasidone Carbidopa/Levodopa, Pramipexole, Ropinirole, Bromocriptine, Amantadine, and Trihexyphenidyl Selegiline Nortriptyline, Protriptyline, Desipramine, Amoxapine, Venlafaxine, Citalopram, Trimipramine Paroxetine, Fluoxetine, Sertraline, Duloxetine, and Bupropion Zolpidem (Quantity Limit 90 tabs Rozerem and Silenor per year) All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia Inc., Cigna HealthCare of Arizona, In., HealthSpring Life and Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealtSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc., The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc., Cigna HealthSpring is contracted with Medicare for PDP plans, HMO, and PPO plans in select states, and wtih select State Medicard programs. Enrollment in Cigna-HealthSpring depends on contract renewal. Celebrex_Form 3 Rev 091614.