Please fill out this form as completely as possible.
Items in yellow are required.
Requester Information
Requester Name
Requester Email Address

Patient Information
Medicaid ID First Name Last Name
Address 1 Address 2
City State Zip DOB
Male Female             Nursing Home Patient Yes No

Prescriber Information
Prescriber Medicaid ID Prescriber Name
Address 1 Address 2 City
State Zip Phone Fax

Pharmacy Information
Pharmacy Medicaid ID Pharmacy Name
Address 1 Address 2 City
State Zip Phone Fax

Clinical Information
NDC Requested    QTY per month
Drug Name    Strength
Diagnosis Comments
Other Comments or Medical Justification
Please select the type of request.       Initial   |   Renewal Number of Refills
Please select the type of therapy.       Acute   |   Maintenance

Drug Specific Information
List previous drug usage and length of treatment as defined in instructions for drug class requested.
***Two Priors are required for initial request, except for Alzheimers Agents.
***One prior is required for Alzheimers Agents.
Generic/Brand/OTC Reason for d/c Therapy start date Therapy end date
Generic/Brand/OTC Reason for d/c Therapy start date Therapy end date

Sustained Release Oral Opiod Agonist Additional Information
Proposed duration of therapy Is medicine for PRN use? Yes No
Type of Pain Acute Chronic Severity of Pain Mild Moderate Severe
Is there a history of substance abuse or addiction? Yes No
***If there is a history of substance abuse, manual form must be completed and treatment plan attached.

Xenical Additional Information
If inital request Weight  kg Height  inches BMI  kg/m2
If renewal request Previous Weight  kg Current Weight  kg
Documented MD supervised exercise/diet regimen ≥ 6 months? Yes No Planned adjunctive therapy? Yes No

Synagis Additional Information
Current Weight  kg
Please check all applicable age, condition and risk factors
Gestational age ≤ 28 wks & infant is < 12 months Child is < 24 months old with Chronic Lung Disease
Gestational age 29 - 32 wks & infant is < 6 months Child is < 24 months old with Congenital Heart Disease
Gestational age 33 - 35 wks & infant is < 6 months with AAP risk factors Currently outpatient with no inpatient stay in the last 2 weeks.
Document AAP risk factor(s) and/or other required medical justification in the Drug/Clinical Information Section of this form

Specialized Nutritionals Additional Information
Current Weight  kg Current Height  inches
If < 21 years of age, record supports that more than 50% of need is met by specialized nutrition
If ≥ 21 years of age, record supports 100% of need is met by specialized nutrition
Method of administration Duration # of refills