TRICARE Pharmacy Program Medical Necessity Form for Rosuvastatin

							               TRICARE Pharmacy Program Medical Necessity Form for Rosuvastatin (Crestor)




        This form applies to the TRICARE Pharmacy Program (TPharm). The medical necessity criteria outlined on this form also apply at Military Treatment
        Facilities (MTFs).
        The form must be completed and signed by the prescriber.
       Formulary statins available at a $9 cost share include atorvastatin (Lipitor), fluvastatin & fluvastatin extended release (Lescol, Lescol XL), lovastatin
        & lovastatin extended release (Altoprev), pravastatin, and simvastatin. Simvastatin/ezetimibe (Vytorin), ezetimibe (Zetia), niacin immediate &
        extended release (Niacor, Niaspan), and lovastatin/niacin (Advicor) are also on formulary. Crestor is non-formulary, but available to most beneficiaries at a $22
        cost share.
       You do NOT need to complete this form in order for non-active duty beneficiaries (spouses, dependents, and retirees) to obtain Crestor at the $22non-formulary cost
        share. The purpose of this form is to provide information that will be used to determine if the use of Crestor instead of a formulary medication is medically necessary. If
        Crestor is determined to be medically necessary based on information that you provide, non-active duty beneficiaries may obtain it at the $9 formulary cost share.
       TRICARE will not cover Crestor for Active duty service members unless it is determined to be medically necessary instead of a formulary medication. If
        Crestor is determined to be medically necessary, it will be available to Active duty service members at no cost share.


                          The provider may call: 1-866-684-4488                                Non-formulary medications are available at MTFs only if both of
                           or the completed form may be faxed to:                                the following are met:
       MAIL ORDER




                           1-866-684-4477                                                        o The prescription is written by a military provider or, at the
         RETAIL




                                                                                                    discretion of the MTF, a civilian provider to whom the patient
                                                                                         MTF        was referred by the MTF.
           and




                          The patient may attach the completed form                             o The non-formulary medication is determined to be medically
                           to the prescription and mail it to: Express Scripts,                     necessary.
                           P.O. Box 52150, Phoenix, AZ 85072-9954
                                                                                                Please contact your local MTF for more information. There are no
                           or email the form only to:
                                                                                                 cost shares at MTFs.
                             TpharmPA@express-scripts.com
                                              There is no expiration date for approved medical necessity determinations.
                        Please complete patient and physician information (Please Print)
        Step                                                                                                   Physician
                                                                                                                 Name:
                       Patient Name:
          1
                        Address:                                                                                Address:

                        Sponsor ID#                                                                          Phone #:
                        Date of Birth:                                                                   Secure Fax #:
        Step            1. Please explain why the patient cannot be treated with any of the formulary alternatives:
                        Please indicate which of the reasons below (1-6) applies to each of the formulary alternatives listed in the table. You
          2             MUST circle a reason AND supply a written clinical explanation specific for EACH formulary alternative.

            Formulary Alternative                                             Reason                                    Clinical Explanation
    Atorvastatin (Lipitor)                                                 1 2 3 4 5 6

    Fluvastatin (Lescol, Lescol XL)                                        1 2 3 4 5 6

    Lovastatin (Mevacor, generics; Altoprev)                               1 2 3 4 5 6

    Pravastatin (Pravachol, generics)                                      1 2 3 4 5 6

    Simvastatin (Zocor, generics)                                          1 2 3 4 5 6

    Simvastatin/ezetimibe (Vytorin)                                        1 2 3 4 5 6
                         Acceptable clinical reasons for not using a formulary alternative are:
                         1. The formulary alternative is not expected to lower LDL sufficiently to meet the patient’s target LDL goal.
                         2. The patient has tried the formulary alternative and failed to reach their target LDL goal.
                         3. The formulary alternative is contraindicated (e.g., due to a hypersensitivity reaction).
                         4. The patient has experienced or is likely to experience significant adverse effects with the formulary alternative.
                         5. The patient requires Crestor because it is not metabolized by the CYP 3A4 system AND the patient cannot meet their target LDL goal
                            with fluvastatin or pravastatin.
                         6. The patient is stabilized on therapy with Crestor, and changing to a formulary statin would incur unacceptable risk (e.g., clinically fragile
                            patients with multiple comorbidities). Please explain the patient-specific risk above.

        Step            I certify that the above is correct to the best of my knowledge (Please sign and date):

          3                                          Prescriber Signature                                          Date
                                                                                                                                                  Latest revision: August 2008