COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES Service Authorization (SA) Form DUR MEDICATION JAKAFI® (ruxolitinib) OR PROMACTA® (eltrombopag) If the following information is not complete, correct, or legible, the SA process can be delayed. Please use one form per member. MEMBER INFORMATION Last Name: First Name: Medicaid ID Number: Date of Birth: – – Gender: Male Female Weight in Kilograms: ___________________________ PRESCRIBER INFORMATION Last Name: First Name: NPI Number: Phone Number: Fax Number: – – – – DRUG INFORMATION Drug Name/Form: ________________________________________________________________________ Strength: _________________________________________________________________________________________________________ Dosing Frequency: _________________________________________________________________________________________________________ Length of Therapy: _________________________________________________________________________________________________________ Quantity per Day: _________________________________________________________________________________________________________ (Form continued on next page.) Virginia Medicaid Pharmacy Services Portal: http://www.virginiamedicaidpharmacyservices.com © 2017–2020, Magellan Health, Inc. All rights reserved. Revision Date: 04/2020 Page 1 of 3 Virginia DMAS SA Form: JAKAFI® or PROMACTA® Member’s Last Name: Member’s First Name: DIAGNOSIS AND MEDICAL INFORMATION JAKAFI® (ruxolitinib) – to receive a ONE (1)-year approval for this drug, complete theses questions: 1. Is the member 18 years of age or older with a diagnosis of intermediate or high-risk myelofibrosis, including primary myelofibrosis, post-polycythemia vera myelofibrosis, or post-essential thrombocythemia myelofibrosis? OR Yes No 2. Is the member 18 years of age or older with a diagnosis of polycythemia vera with an inadequate response to or intolerance to hydroxyurea? OR Yes No 3. Is the member 12 years of age or older with a diagnosis of steroid-refractory acute graft-versus-host disease? AND Yes No 4. Will the member have liver function tests (LFTs) performed monthly? Yes No PROMACTA® (eltrombopag) – to receive a ONE (1)-year approval for this drug, complete these questions: 1. Is the member 1 year of age or older with a diagnosis of thrombocytopenia with chronic immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy? OR Yes No List past failures: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Is the member being treated for thrombocytopenia with chronic hepatitis C to allow the initiation and maintenance of interferon-based therapy? OR Yes No (Form continued on next page.) Virginia Medicaid Pharmacy Services Portal: http://www.virginiamedicaidpharmacyservices.com © 2017–2020, Magellan Health, Inc. All rights reserved. Revision Date: 04/2020 Page 2 of 3 Virginia DMAS SA Form: JAKAFI® or PROMACTA® Member’s Last Name: Member’s First Name: 3. Is the member 2 years of age or older with Promacta® being used in combination with standard immunosuppressive therapy (IST) for the first-line treatment of severe aplastic anemia? OR Yes No 4. Is the member being treated for severe aplastic anemia and has the member had an insufficient response to immunosuppressive therapy? Yes No Prescriber Signature (Required) Date By signature, the Physician confirms the above information is accurate and verifiable by member records. Please include ALL requested information; Incomplete forms will delay the SA process. Submission of documentation does NOT guarantee coverage by the Department of Medical Assistance Services. The completed form may be: FAXED TO 800-932-6651, phoned to 800-932-6648, or mailed to: Magellan Medicaid Administration / ATTN: MAP 11013 W. Broad Street, Glen Allen, VA 23060 Virginia Medicaid Pharmacy Services Portal: http://www.virginiamedicaidpharmacyservices.com © 2017–2020, Magellan Health, Inc. All rights reserved. Revision Date: 04/2020 Page 3 of 3 .