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Drug Prior Authorization FAX Form

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Drug Prior Authorization FAX Form Powered By Docstoc
					                                                                                                    SPORANOX (itraconazole),
                                                                                                       LAMISIL, PENLAC
                                                                                                                 Antifungals

Drug Prior Authorization FAX Form
         Please complete information, sign, date and FAX to the FLRx Pharmacy Help Desk:
                                       Fax Number: 800-956-2397
                          Please allow 3 business days for review of this request.

                 Please complete all of the following Patient/Physician Information:
Patient Name: (Please Print)

FLRx Patient ID number:                                                        Patient Birthdate:
MD Name:                                                                       MD Specialty:
MD Provider number:                                                            MD Phone #: (                 )
MD DEA #:                                                                      MD FAX #:      (              )

QUESTIONS / INDICATIONS FOR MEDICAL NECESSITY:
1. This request is for:       Lamisil       Sporanox          Penlac
*Please note: Penlac is rarely approved due to poor clinical cure response rate (6-8% reported in US trials).
2. Diagnosis: (required to complete review) Onychomycosis           Other:
3. Name and therapeutic response to all drugs tried to treat this condition:

If Diagnosis is Onychomycosis please complete the following:
Please note:
Lamisil is the drug of choice for treating onychomycosis – better cure rate, less drug interactions, most cost effective.
Sporanox will not be approved unless specific intolerance to Lamisil or organism not sensitive to Lamisil.                  YES   NO
4. Is the therapy requested for a    fingernail or  toenail infection? (Please check)
5. Is the therapy primarily being used to improve the cosmetic appearance of the nail?
6. Does the patient have concomitant medical conditions such as:
      (please check all that apply)
           Diabetes
           Immunocompromise
           Neuropathy
           Circulatory Disease (i.e. PVD and PAD)
           Other Clinical Information:

7. Does the patient have toenail or fingernail fungal infection documented with a
   positive fungal culture or “KOH”? (POSITIVE CULTURE/KOH IS A REQUIREMENT.)
Sporanox should NOT be administered for the treatment of onychomycosis in patients with ventricular dysfunction such as
CHF or a history of CHF. If signs or symptoms of CHF occur during treatment for onychomycosis, Sporanox should be
discontinued. The FDA believes that the risk of CHF associated with Sporanox is due to its negative inotropic effect.
www.fda.gov/cder/drug/advisory/sporanox-lamisil/advisory.htm
Max. Treatment Approval for Onychomycosis:
              Fingernail: 6 weeks (42 days; suggest Rx 21 days with one refill)
              Toenail: 12 weeks (84 days, suggest 28 days of therapy, 2 refills)

Other Comments/Justification:


I certify that the above information is true and accurate to the best of my knowledge.
Prescriber Signature                                            Date
             IF YOU WOULD PREFER TO CALL THIS INFORMATION INTO THE FLRx PHARMACY HELP DESK DIRECTLY;
                    PHONE #: 1-800-724-5033 (out of area) Rochester local #: 454-5338                            11/05

				
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posted:8/30/2011
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