02/26/2015 Service Authorization CHRISTUS Health Plan (Medicaid) Relistor (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CHRISTUS Health Plan (Medicaid) at 1-866-255-7569. Please contact CHRISTUS Health Plan (Medicaid) at 1-855-656-0363 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Relistor (Medicaid). Drug Name (select from list of drugs shown) Relistor (methylnaltrexone) Quantity Route of Administration Frequency Expected Length of therapy Strength Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Patient Phone: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. 1. Does the patient have a diagnosis of opioid induced constipation in the last 730 days? Circle Yes or No Y N [If the answer to this question is no, then no further questions required.] 2. Does the patient have a history of palliative care in the last 365 days? Y N Y N [If the answer to this question is no, then no further questions required.] 3. Is the patient 18 years of age or older? [If the answer to this question is no, then no further questions required.] 4. Does the patient have a diagnosis of mechanical gastrointestinal obstruction in the last 730 days? Circle Yes or No Y N [If the answer to this question is yes, then no further questions required.] 5. Has the patient had a claim for a laxative in the last 90 days? Y N Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date