Topical Immunomodulators Prior Authorization Worksheet New York State Medicaid Clinical Drug Review Program If your fax includes the standardized fax form, only the Member Name, ID, DOB, and Clinical Criteria need to be completed and faxed as an attachment to process your request. Enrollee Information (2 5 1 Prescriber Information (NPI): Clinical Criteria Which drug are you requesting? (Document name, strength, direction, quantity, and number of refills.) Elidel 1% and Protopic 0.03% ointment have a minimum age limit of 2 years. Protopic 0.1% ointment has a minimum age limit of 16 years. Elidel Protopic Is the patient diagnosed with atopic dermatitis? Yes No Did the patient attempt using a topical corticosteroid for four (4) weeks? Yes No Has the patient experienced any of the following? Please check all that apply and document what the failure, adverse reaction, and/or contraindication was. A treatment failure with a topical corticosteroid
Topical Immunomodulators Prior Authorization Worksheet New York State Medicaid Clinical Drug Review Program If your fax includes the standardized fax form, only the Member Name, ID, DOB, and Clinical Criteria need to be completed and faxed as an attachment to process your request. Enrollee Information (2 5 1 Prescriber Information (NPI): Clinical Criteria Which drug are you requesting? (Document name, strength, direction, quantity, and number of refills.) Elidel 1% and Protopic 0.03% ointment have a minimum age limit of 2 years. Protopic 0.1% ointment has a minimum age limit of 16 years. Elidel Protopic Is the patient diagnosed with atopic dermatitis? Yes No Did the patient attempt using a topical corticosteroid for four (4) weeks? Yes No Has the patient experienced any of the following? Please check all that apply and document what the failure, adverse reaction, and/or contraindication was. A treatment failure with a topical corticosteroid