Download Question Circle Yes or No 1. Does the patient have New York Heart

12/15/2016
Prior Authorization
AETNA BETTER HEALTH OF MICHIGAN (MEDICAID)
Entresto (MI88)
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Complete/review information, sign and date. Fax signed forms to Aetna Better Health of Michigan at 1-855-799-2551.
Please contact Aetna Better Health of Michigan at 1-866-316-3784 with questions regarding the Prior Authorization process.
When conditions are met, we will authorize the coverage of Entresto (MI88).
Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise.
Drug Name (select from list of drugs shown)
Entresto (sacubitril/valsartan)
Other, Please specify: ________________________________
Quantity
Route of Administration
Frequency
Expected Length of therapy
Strength
Patient Information
Patient Name:
Patient ID:
Patient Group No.:
Patient DOB:
Patient Phone:
Prescribing Physician
Physician Name:
________________________________________________________________________
Specialty:
___________________________
NPI Number:
_________________________
Physician Fax:
___________________________
Physician Phone:
_________________________
Physician Address:
___________________________
City, State, Zip:
_________________________
Diagnosis:
ICD Code:
Please circle the appropriate answer for each question.
Question
1. Does the patient have New York Heart Association
Class 2-4 (NYHA Class II-IV) Heart Failure AND a
reduced ejection fraction of less than or equal to 40
percent?
Circle Yes or No
Y
N
[If no, then no further questions]
2. Is the patient tolerating an ACEI (angiotensinconverting-enzyme inhibitor) or ARB (angiotensin
receptor blocker)?
[If no, then no further questions]
Y
N
Question
3. Will the ACEI or ARB be stopped when the patient
starts Entresto?
Circle Yes or No
Y
N
[If no, then no further questions]
4. Will Entresto be used with other heart failure
therapies such as beta blockers, aldosterone
antagonist, and/or hydralazine plus isosorbide?
Y
N
Y
N
Y
N
Y
N
[If no, then no further questions]
5. Is the patient pregnant?
[If yes, then no further questions]
6. Does the patient have severe hepatic impairment
(Child Pugh Class C)?
[If yes, then no further questions]
7. Is the patient 18 years of age or older?
Comments:
I affirm that the information given on this form is true and accurate as of this date.
Prescriber (Or Authorized) Signature
Prescriber (Or Authorized) Signature
Date
Date