Sporanox (itraconazole) PRIOR AUTHORIZATION FORM Coverage Policy: Covered for invasive fungal infections such as histoplamosis, aspergillosis, and blastomycosis in patients who are immunocompromised. Covered for topical fungal infections when criteria as described below are met. *Diflucan (fluconazole) and Lamisil (terbinafine) are available generically without authorization. PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE – PHARMACEUTICAL SERVICES FA X:Q 3 ( 8 7 7 ) 5 5 4 - 9 1 3 9 P H O N E : ( 8 7 7 ) 2 1 5 - 4 0 9 8 Requesting Physician: Call Center ID: Office Contact: Tax ID Number: Plan ID: Benefit: Office Fax Number: Phone Number: Office Address: MEMBER INFORMATION Patient Name: DOB: Member ID#: Date of Request: May 4, 2008 MEDICATION INFORMATION 1. Dosage Requested: ______________________________________ 2. 3. 4. Is the patient immunocompromised? (transplant, chemotherapy, diabetes, other) YES condition: __________________________________ NO Does the patient have a history of CHF? YES NO Does the patient have impaired Liver Function? YES NO Diagnosis: Esophageal Candidiasis - Oral treatment authorized after failure of oral Nystatin suspension and terbinafine Majocchi’s Granuloma - Treatment approved for up to 6 weeks Oral thrush - Oral treatment authorized after failure of oral Nystatin suspension or Mycelex Troches, and terbinafine Tinea Barbae - Treatment approved for up to 4 weeks after failure of terbinafine Tinea Capitis - Treatment approved for up to 4 weeks after failure of terbinafine Tinea Corporis - Treatment up to 2 weeks authorized after failure of topical antifungals and terbinafine Tinea Cruris - Treatment up to 2 weeks authorized after failure of topical antifungals and terbinafine Tinea Faciei - Treatment up to 2 weeks authorized after failure of topical antifungals and terbinafine Tinea Favosa - Treatment approved for up to 4 weeks after failure of terbinafine Tinea Manuum - Treatment up to 4 weeks authorized after failure of topical antifungals and terbinafine Tinea Pedis (w/o nail involvement) - Treatment up to 4 weeks approved after failure of topical antifungals and terbinafine Tinea Unguium (Onychomycosis) - please submit information with an Onychomycosis Form Tinea Versicolor - Treatment for up to 1 week authorized after failure of topical selenium sulfide and topical antifungals Other (please explain): __________________________________________________________________________ CURRENT/PAST MEDICATIONS/DOSAGES USED DATES OF TREATMENT THERAPEUTIC OUTCOME 5. 6. Has a culture, PAS or KOH been done? YES (please include results) NO Physician’s Signature: CHCH 5121-10 (03/08) Visit our Website at WWW.CVTY.COM Fax Confidentiality Notice: The information contained in this transmission is confidential, proprietary or privileged and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act (HIPAA). The message is intended for the sole use of the individual or entity to whom it is addressed. If you are not the intended recipient, you are notified that any use, distribution or copying of the attached material is strictly prohibited and may subject you to criminal or civil penalties. If you received this transmission in error please notify us immediately by telephone at 1-877-215-4100.
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