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Risperdal consta injection authorization request form
Risperdal Consta Injection
(All requests must be approved in advance to ensure authorization)
Fax to Magellan: 888-656-4919
Provider: __________________________________ Contact: _______________________________________
Phone Number: _____________________ MIS #: _______________________________________________
Address: _________________________________ Member Name: __________________________________
Medicaid Managed Care #: ___________________________________________________________________ Dx
: Axis I: ____________________________________________________________________________________
Axis II: ___________________________________________________________________________________ Axis III: __________________________________________________________________________________ Axis IV: ___________________________________________________________________________________ Axis V Current GAF: ____________ Past Year: _________
Guidelines for Approval
1. Patient has a DSM diagnosis within the range; 295. To 298.9. (Other diagnoses require supporting medical documentation).
2. Patient has been tried on other antipsychotic injectables without success or other antipsychotic injectables have been considered.
3. Patient has been tried unsuccessfully with other oral medications. List
4. Patient is unable to take the oral form due to current medical conditions. Describe
5. Patient is currently being treated with other depot medications but is experiencing either adverse side effects or breakthrough
Questions 1 and 2 must be answered and at least one of 3,4, or 5 for authorization.
Patient does not have a diagnosis of schizophrenia or schizoaffective disorder
Patient is under 18 years of age.
Patient is not able to tolerate a minimum of 2mg/day of oral risperidone,
Patient is adherent and successfully treated with other antipsychotic medication therapy.
The provider is not the only prescriber of antipsychotic medication for the patient
Is patient stable on current dosage and needs a longer than one month authorization? Yes/No
Please extend authorization for ___________________________ months or __________________________________ injections.
Dosage given on each appointment date: ____________________________ (mg)
Dates of injections: ____________; ____________; _____________; _______________; _______________; __________________
J2794 (Risperidone) x ______________ Units (25 mg = 50 units; 37.5 mg = 75 units; 50mg = 100 units)
96372 (injection) x __________ (number of injections)
Authorization #: ___________________________________________________________________________________________
□ Please Fax this Form with the authorization # back to Provider: ____________________________________________________ □ Please call us back with authorization #
Partnerships for Older People Project Domiciliary Medicine Use Review by Medicines Management and Pharmacy Team, July 2007-Mar 2008 October 2008 Cathal Doyle, RDC (Cathal.email@example.com) & Bola Sotubo, Medicines Management and Pharmacy Team, Southwark Health & Social Care 1. Introduction This report analyses the data collated from the
Iranian Journal of fisheries Sciences 12(4)802-812 2013 Isolation, identification and phylogenetic analysis of a pathogen of Haliotis diversicolor supertexta (L.) with mass mortalities Zhou Jing*1 and Cai Junpeng2 Received: February 2013 Accepted: April 2013 Abstract This study was conducted to determine a disease outbreak in 14 day old post-larvae of abalone ( Haliotis dive