Sporanox (itraconazole) PRIOR AUTHORIZATION FORM

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)
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