Prior Authorization Request Form (Physician to Complete)
Refer to www.wellmark.com to see specific clinical
requirements for the requested drug. All necessary elements
must be completed for review consideration.
P-23386 1/16
Patient Information PresPrescriber Information
Patient Name: Prescriber Name:
Patient ID: Prescriber Specialty:
Gender: M or F
DOB: / / Address:
Diagnosis City: State:
Diagnosis: Disease Duration: Phone Number: Fax Number: Zip:
Diagnosis (ICD) Code(s): Contact Person at Prescriber’s
Oce:
DEA Number:
Medication Information
Medication: Strength: Frequency: Quantity:
Expected Length of Therapy:
Does the patient require a specific dosage form? Yes No
If yes, please explain:
Medical rationale for use: Specific directions for use:
Is this is a continuation of therapy: Yes No
How long has the patient been on the medication (provide treatment dates): _________________________________________________
Are they currently stable on/benefiting from therapy? Yes No
Specify anticipated significant adverse event if medication changed: _______________________________________________________
Provide objective measurements to demonstrate improvement/stabilization, if required: _________________________________________
FORM CANNOT BE EVALUATED WITHOUT REQUIRED CLINICAL INFORMATION
Please complete form and fax back to (888) 836-0730 for non-specialty drugs and (866) 249-6155 for specialty drugs or call (800) 600-8065
1. Please list all current and past medications and therapies the patient has tried specific to the diagnosis and specify below:
Medications/Therapies*
(if drug therapy, specify drug name/dose)
Dates of therapy/treatment duration
Outcome of Therapy
(allergy, adverse event - specify and include
severity, treatment failure, inadequate response)
*include non-drug therapy trials (i.e. CPAP, PUVA)
2. Please list any medications specific to the diagnosis that are contraindicated or medically necessary to avoid (include rationale):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
3.Please list and provide medical records of any laboratory results, diagnostic tests, or required monitoring needed for the requested
medication and diagnosis (include dates): ___________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
4. Medical documentation is required for the requested drug and is attached: Yes No
5. Please provide additional relevant information: ______________________________________________________________________
REFER TO NEXT PAGE FOR ADDITIONAL INFORMATION ON SPECIFIC MEDICATIONS
_____________________________________________________
Printed Name
_____________________________________________________
Signature
Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended
recipient, you hereby are advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received this fax in error, please
immediately notify the sender by telephone and destroy this original fax message.
Visit www.wellmark.com for additional drug/class specific clinical criteria, preferred drug
list, and formulary information.
Please ensure member’s name, DOB and ID number are on all additional submitted documents.
Biologicals • Medical records from any physician visit, ED visit, or hospitalization in the past year
• Results from any recent colonoscopy or other relevant GI study if applicable to diagnosis
Esbriet and Ofev • Chart notes, and/or documentation to support diagnosis of idiopathic pulmonary fibrosis
• Results from a high resolution computed tomography (HRCT) study of the chest
• Pathology report from a surgical lung biopsy, if applicable
• Laboratory results: liver function tests
Growth Hormone • Medical records supporting the diagnosis
• Pretreatment growth hormone provocative test result(s) (laboratory report or medical record documentation)
• Pretreatment and/or current IGF-1 level (laboratory report or medical record documentation)
• The following laboratory test reports must be provided:
• diagnostic karyotype results in Turner syndrome
• diagnostic genetic test results in Prader-Willi syndrome
• diagnostic molecular or genetic test results in SHOX deficiency
• Documentation of current anti-retroviral therapy regimen for members with HIV-associated wasting/cachexia
Hepatitis • Complete medical records including: recent progress notes, genotype, subtype, proposed treatment regiment,
liver stage or fibrosis score (including name of scoring system), treatment history, clinical reason that precludes
Harvoni as a treatment option, comorbidities
IVIG • Documentation for why IVIG is not an option for the patient if SQ IG is being requested
• Please attach documentation and lab results: (1) Laboratory evidence of the primary immunodeficiency: total
IgG level or other laboratory evidence such as absence of B lymphocytes (2) Documented inability to mount an
adequate immunologic response to inciting antigens AND (3) Documentation of persistent and severe infections
despite treatment with prophylactic antibiotics
Juxtapid and Kynamro • Laboratory results, chart notes, and/or documentation of genetic or molecular testing to support diagnosis of
homozygous familial hypercholesterolemia
• Untreated baseline and current LDL and triglyceride level
• documentation of current and previous treatment regimen
• For renewal requests, liver function tests with ALT, AST, and bilirubin
Makena • Medical records documenting current gestational age
Pulmonary Arterial
Hypertension
• Report with pretreatment results from right heart catheterization
• Documented date of pulmonary endarterectomy if requesting Adempas for PAH, WHO Group 4 (CTEPH)
PCSK9s • Laboratory results, chart notes, and/or documentation of genetic or molecular testing to support diagnosis of
of familal hypercholesterolemia, if applicable
• Untreated baseline LDL and most recent LDL (within 30 days of request)
• Pharmacy refill history establishing adherence with statin and ezegtimibe
• Medical chart notes documenting contraindications and/or medical reasons that preclude statin use
• Body mass index (BMI)
Synagis • Initiate enrollment by contacting Hy-Vee Pharmacy Solutions at (866) 823-9868
Xolair • Medical records from any physician visits/ED visits in the past year
• The patient’s pretreatment AND current UAS7 urticaria activity score
Viscosupplementation • Synvisc-One is the preferred product
• Initiate enrollment by contacting Hy-Vee Pharmacy Solutions at (877) 794-9833
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