TRICARE Pharmacy Program Medical Necessity Form for Avapro, Benicar by smapdi55

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									                      TRICARE Pharmacy Program Medical Necessity Form for
                     Avapro, Benicar, Diovan, Teveten, and HCTZ Combinations


THIS FORM MUST BE COMPLETED AND SIGNED BY THE PRESCRIBER. This form applies to the TRICARE Pharmacy (TPharm) programs. The medical
necessity criteria outlined on this form may also apply to Military Treatment Facilities (MTF’s).
 Angiotensin receptor blockers (ARBs) on the DoD Uniform Formulary include Atacand (candesartan), Cozaar (losartan), Micardis (telmisartan), and
   their hydrochlorothiazide (HCTZ) combinations. Avapro (irbesartan), Benicar (olmesartan), Diovan (valsartan), Teveten (eprosartan), and their
   HCTZ combinations are non-formulary, but available to most beneficiaries at a $22 cost share.
 The purpose of this form is to provide information that will be used to determine if the use of a non-formulary medication instead of a formulary
   medication is medically necessary. If a non-formulary medication is determined to be medically necessary, non-Active duty beneficiaries may obtain it
   at the $9 formulary cost share.
 TRICARE will not cover a non-formulary medication for Active duty service members unless it is determined to be medically necessary instead of a
   formulary medication, in which case 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
    MAIL ORDER




                       or the completed form may be faxed to:                         the following are met:
                       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
        and




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


             Date of Birth:                                                                   Phone #:
             Sponsor ID #:                                                                    Secure Fax #:
  Step     1. Please indicate which medication is being prescribed:
             □ Avapro, Avalide (irbesartan +/HCTZ)                     □ Diovan, Diovan HCT (valsartan +/HCTZ)
    2        □ Benicar, Benicar HCT (olmesartan +/HCTZ)                □ Teveten, Teveten HCT (eprosartan +/HCTZ)
           2. Please explain why the patient cannot be treated with a formulary alternative:
                 Please indicate which of the reasons below (1-7) applies to each of the formulary alternatives listed in the table. You MUST
                 circle a reason AND supply a SPECIFIC written clinical explanation for EACH formulary alternative.
              Formulary Alternative           Reason                                    Detailed Clinical Explanation
            Atacand, Atacand HCT
                                            1 2 3 4 6
            (candesartan +/HCTZ)
            Cozaar, Hyzaar
                                           1 2 3 5 6 7
            (losartan +/HCTZ)
           Micardis, Micardis HCT
                                              1 2 3 6
           (telmisartan +/HCTZ)
           1. Use of the formulary alternative is contraindicated (e.g., due to hypersensitivity).
           2. The patient has experienced significant adverse effects from the formulary alternative.
           3. Use of the formulary alternative has resulted in therapeutic failure.
           4. Diovan or Diovan HCT only - The patient has heart failure AND treatment with Atacand or Atacand HCT has resulted in therapeutic
                failure, was associated with significant adverse effects, or is contraindicated. The patient is not required to try Cozaar, Micardis, or their
                HCTZ combinations.
           5. Avapro or Avalide only - The patient has type 2 diabetic nephropathy AND treatment with Cozaar or Hyzaar has resulted in therapeutic
                failure, was associated with significant adverse effects, or is contraindicated. The patient is not required to try Atacand, Micardis, or their
                HCTZ combinations.
           6. The patient previously responded to Avapro, Benicar, Diovan, or Teveten (or their HCTZ combinations) and changing to any formulary
                alternative would incur an unacceptable clinical risk to the patient (e.g., risk of destabilization, abrupt worsening of symptoms). Note:
                some circumstances under which this criterion may apply are: 1) post-myocardial infarction patients who are stabilized on Diovan, or 2)
                chronic heart failure patients stabilized on a non-formulary ARB or ARB/HCTZ combination for whom changes in therapy might result in
                destabilization.
           7. Diovan only - The patient is 6-16 years of age with hypertension AND has experienced significant adverse effects or therapeutic failure
                with Cozaar. The patient is not required to try Atacand or Micardis.

  Step        I certify the above is correct and accurate to the best of my knowledge. Please sign and date:

    3
                                        Prescriber Signature                                             Date
                                                                                                                              Latest revision: August 2008

								
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