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. Explain:
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
symptoms. Explain:
Questions 1 and 2 must be answered and at least one of 3,4, or 5 for authorization.

Exclusion Guidelines
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 #

Source: http://magellanprovider.com/MHS/MGL/about/handbooks/supplements/ne_medicaid/appD/8.pdf