MaineCare/medel prior Authorization Form



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Form # 10210.18

R:02.17


State of Maine Department of Health & Human Services

MaineCare/MEDEL Prior Authorization Form

BOTULINUM

Phone: 1-888-445-0497 www.mainecarepdl.org Fax: 1-888-879-6938


Member ID #: |__|__|__|__|__|__|__|__|__| Patient Name: ____________________________________ DOB: __________________

(NOT MEDICARE NUMBER)

Patient Address:_________________________________________________________________________________________________


Provider DEA: |__|__|__|__|__|__|__|__|__| Provider NPI: __|__|__|__|__|__|__|__|__|__|

Provider Name:_______________________________________________________________________ Phone:____________________


Provider Address:_____________________________________________________________________ Fax:____________________
Pharmacy Name:_____________________________Rx Address:________________________________Rx phone:_________________

Provider must fill all information below. It must be legible, correct and complete or form will be returned.



(Pharmacy use only): NPI: __|__|__|__|__|__|__|__|__|__| NABP: |__|__|__|__|__|__|__| NDC: |__|__|__|__|__|__|__|__|__|__|__|





Requesting prescriber (if not a neurologist, physiatrist or orthopedist) must provide documentation of adequate training for injection procedure. (please supply certificate)

Who will supply this product to the patient?

Pharmacy-fax to 1-888-879-6938 OR

Prescriber-fax to 1-866-598-3963 Provider ID#_________________



Dosage Days Supply

Drug Name Strength Instructions Quantity (34 days max) Refills
BOTOX® (J0585) _________ __________ __________ _____________ 1 2 3 4 5

All requests for prior authorization of Botox® that gain approval will be limited to:

  • Maximum 600U per injection session for adults (400U per injection for children >12 yrs of age).

  • Injection sessions are not to occur any more frequently than 90 days apart.

  • Initial approvals will be valid for a six-month period (until adequate clinical response is proven).

Indication:

□ Cervical dystonia □ Occupational dystonia □ Spasticity (see below) □ Hemifacial spasms □ Spastic dysphonia

□ Oromandibular dystonia □ Multiple Sclerosis □ Spasmodic torticollis □ Strabismus and blepharospasm associated with dystonia

□ Dynamic muscle contracture associated with cerebral palsy □ Other ________________________________________________


Medically Necessity Documentation (required for spasticity treatment only):

□ Failed adequate therapeutic trials of muscle relaxants, including but not limited to baclofen, clonidine, dantrium, and tizanidine.


DYSPORT® (J0586) _________ __________ __________ _____________ 1 2 3 4 5

All requests for prior authorization of Dysport® that gain approval will be limited to:

  • Maximum 1,000U per injection session for adults

  • Injection sessions are not to occur any more frequently than 90 days apart.

  • Initial approvals will be valid for a six-month period (until adequate clinical response is proven).

Indication:

Cervical dystonia □ Spastic hemiplegia □ Spastic di/hemi/quadriplegic Cerebral Palsy □ Quadriplegia C5-C7

Diplegia of upper limbs □ Monoplegia of upper limb □ Hemiplegia and hemiparesis □ Other _________________________
MYOBLOC® (J0587) _________ __________ __________ _____________ 1 2 3 4 5

All requests for prior authorization of Myobloc® that gain approval will be limited to:



  • Total maximum dose per visit = 15,000 U and Maximum dose per injection site = 2,500 U

  • Injection sessions are not to occur any more frequently than 90 days apart

  • Initial approvals will be valid for a six month period (until adequate clinical response is proven).

Indication:

Cervical dystonia □ Other _________________________


Pursuant to the MaineCare Benefits Manual, Chapter I, Section 1.16, The Department regards adequate clinical records as essential for the delivery of quality care, such comprehensive records are key documents for post payment review. Your authorization certifies that the above request is medically necessary, meets the MaineCare criteria for prior authorization, does not exceed the medical needs of the member and is supported in your medical records.
Provider Signature: ______________________________________ Date of Submission: _______________________________

*MUST MATCH PROVIDER LISTED ABOVE



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