Certificate of Medical Necessity

Certificate of Medical Necessity

Omalizumab (Xolair®) J2357

Please fax completed CMN forms and other required documentation (i.e., physician history and physical; physician progress notes; with documentation of conservative treatment including prior medications used; treatment plan including narrative).

Statewide fax number: 904-905-9849

SECTION A

Provider Information

Name

/

BCBSF Number

/

National Provider Identifier (NPI)

Street Address

/

City

/

State

/

Zip

Telephone Number

/

Fax Number

Contact Name

Member Information

Last Name / First Name
Member/Contract Number (alpha and numeric) / Weight:
Date of Birth / Age:

SECTION B

Please provide diagnosis code and description. ICD9 code ______Description ______
Is patient picking up medication at a retail pharmacy? / Yes No N/A
Is provider buying the medication and billing BCBSF directly? / Yes No N/A
Is provider obtaining medication from Caremark for drug replacement? / Yes No N/A
Is this the initial request or continuation of therapy. If continuation, what date was therapy initiated? ______
Please provide prescribed dosage (milligrams, administration route, frequency): ______

SECTION C

Please answer the following questions: / Check Response
A.  Is the patient 12 years of age or older? / Yes No
B.  Is there documentation of moderate to severe asthma? / Yes No
C.  Is there documentation of a positive skin test or in vitro reactivity to a perennial aeroallergen? / Yes No
D.  Are asthma symptoms inadequately controlled with moderate to high dose inhaled corticosteroids AND combination therapy such as leukotriene modifier (Singulair®, Accolate®, Zyflo®, etc.) OR a long acting beta agonist (Serevent®; Advair®, Foradil®, Dulera®, Symbicort®, etc)? (Please specify which medications under classification below) / Yes No
a.  Short-acting beta-agonist (SABA) ______/ Current Past
b.  Inhaled corticosteroids (ICS without LABA)______/ Current Past
c.  Long-acting beta-agonist (LABA without ICS) ______/ Current Past
d.  Combination therapy (ICS/LABA) ______/ Current Past
e.  Oral Steroids ______/ Current Past
f.  Other: ______/ Current Past
E.  Are baseline pretreatment serum total IgE measurements between 30 IU/ml and 700 IU/ml? / IgE level: ______
Date drawn: ______

Comments: ______

Form completed by:

Name/Title (Printed):
Signature: / ______/ Date: