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OptumRx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations. Visit go.covermymeds.com/OptumRx to begin using this free service. Please note: All information below is required to process this request. Mon-Fri: 5am to 10pm Pacific / Sat: 6am to 3pm Pacific Zyvox® (linezolid) Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Member Information (required) Provider Information (required) Member Name: Provider Name: Insurance ID#: NPI#: Date of Birth: Office Phone: Street Address: Office Fax: City: State: Zip: Phone: Specialty: Office Street Address: City: State: Zip: Medication Information (required) Medication Name: Strength: Check if requesting brand Check if request is for continuation of therapy Directions for Use: Dosage Form: Clinical Information (required) Select the diagnosis below: Chronic osteomyelitis or prosthetic joint infection caused by methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-resistant Staphylococcus epidermidis (MRSE) Community-acquired pneumonia caused by MRSA Community-acquired pneumonia caused by methicillin-susceptible Staphylococcus aureus (MSSA) Community-acquired pneumonia caused by Streptococcus pneumoniae (including multi-drug resistant strains [MDRSP]) Complicated skin/skin structure infection (including diabetic foot infection) without osteomyelitis caused by MRSA Complicated skin/skin structure infection (including diabetic foot infection) without osteomyelitis caused by MSSA, Streptococcus pyogenes, or Streptococcus agalactiae Empirical treatment of complicated skin/skin structure infection (including diabetic foot infection) without osteomyelitis where MRSA infection is likely Empirical treatment of uncomplicated skin/skin structure infection where MRSA infection is likely Invasive vancomycin-resistant Enterococcus faecium (VRE) infection Nosocomial pneumonia caused by MRSA Nosocomial pneumonia caused by MSSA or Streptococcus pneumoniae (including MDRSP) Symptomatic lower urinary tract infection caused by VRE Uncomplicated skin/skin structure infection caused by MRSA Uncomplicated skin/skin structure infection caused by MSSA or Streptococcus pyogenes Other diagnosis: ______________________________ ICD-10 Code(s): _____________________________________ If the patient has End-Stage Renal Disease (ESRD), select all that apply: The medication is being used to treat infections related to ESRD The dialysis provider (i.e., nephrologist, nurse practitioner, physician assistant, or dialysis center) receives a monthly capitation payment to manage the ESRD patient’s care Continuation of therapy: Is the requested medication being used for continuation of therapy upon hospital discharge? Yes No Is the requested medication being used for continuation of therapy when transitioning from intravenous (IV) daptomycin (Cubicin), IV vancomycin (Vancocin), IV tigecycline (Tygacil), IV telavancin (Vibativ), or IV linezolid (Zyvox) therapy? Yes No If yes, please specify: ____________________. Culture & Sensitivity: Has the patient's diagnosis been confirmed by a culture and sensitivity report? Yes No Diagnosis of chronic osteomyelitis or prosthetic joint infection: Is this for reauthorization? Yes No Will chart documentation be submitted to OptumRx® with this form, from an infectious disease specialist confirming that prolonged treatment is necessary? Yes No Infectious disease specialist: Was the requested medication prescribed by or in consultation with an infectious disease specialist? Yes No ______________________________________________________________________________________________________________ This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately. Office use only: Zyvox_CMS_2017Jan1-W Zyvox® (linezolid) Prior Authorization Request Form (Page 2 of 2) DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Select the medications the patient has a failure, contraindication or intolerance to: Amoxicillin-clavulanate Carbapenems (e.g., Invanz, meropenem, imipenem-cilastin) Ampicillin-sulbactam Macrolides (e.g., azithromycin, clarithromycin, erythromycin) Cefotaxime Other cephalosporins (e.g., cefdinir, cefprozil, cephalexin) Ceftriaxone Other fluoroquinolones (e.g., ciprofloxacin) Clindamycin Other penicillins (e.g., amoxicillin, penicillin G) Dicloxacillin Other tetracyclines (e.g., minocycline, tetracycline) Doxycycline Levofloxacin Moxifloxacin (Avelox) Nitrofurantoin Trimethoprim-sulfamethoxazole (Bactrim) Select the medications the patient has a resistance to: Amoxicillin-clavulanate Carbapenems (e.g., Invanz, meropenem, imipenem-cilastin) Ampicillin-sulbactam Macrolides (e.g., azithromycin, clarithromycin, erythromycin) Cefotaxime Other cephalosporins (e.g., cefdinir, cefprozil, cephalexin) Ceftriaxone Other fluoroquinolones (e.g., ciprofloxacin) Clindamycin Other penicillins (e.g., amoxicillin, penicillin G) Dicloxacillin Other tetracyclines (e.g., minocycline, tetracycline) Doxycycline Levofloxacin Moxifloxacin (Avelox) Nitrofurantoin Trimethoprim-sulfamethoxazole (Bactrim) For brand Zyvox, select the medications the patient has a failure, contraindication, or intolerance to: Linezolid Zyvox suspension Quantity limit requests: What is the quantity requested per DAY? ______ What is the reason for exceeding the plan limitations? Titration or loading-dose purposes Patient is on a dose-alternating schedule (e.g., one tablet in the morning and two tablets at night, one to two tablets at bedtime) Requested strength/dose is not commercially available There is a medically necessary justification why the patient cannot use a higher commercially available strength to achieve the same dosage and remain within the same dosing frequency. Please specify: _____________________________________________ Other: ______________________________________________________________________________________________________ Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review? ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Please note: This request may be denied unless all required information is received. If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. For urgent or expedited requests please call 1-800-711-4555. This form may be used for non-urgent requests and faxed to 1-800-527-0531. ______________________________________________________________________________________________________________ This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately. Office use only: Zyvox_CMS_2017Jan1-W