Download Megestrol Oxandrolone

Request for Prior Authorization – Weight Gain Promoting Agents
Website Form – www.highmarkhealthoptions.com
Submit request via: Fax - 1-855-476-4158
Client name _________________________________________ DOB: ________________________________________________
Medicaid ID Number: __________________________________ Date of Request:_______________________________________
Practitioner Name:____________________________________ NPI:__________________________________________________
Office Phone Number: _________________________________ Office Fax Number: ____________________________________
Megestrol (Megace), Oxandrolone (Oxandrin), Dronabinol (Marinol)
Covered Conditions:
• Treatment of anorexia associated with weight loss in patients with AIDs
• Treatment of anorexia associated with chemotherapy/radiation therapy
• Palliative treatment of breast and endometrial carcinoma
General Requirements:
• Minimum age for authorization is 18 years
• Failure of conventional therapies
Drug Name
Max Dose
Megestrol
(Megace)
800mg
Oxandrolone
(Oxandrin)
20 mg
Dronabinol
(Marinol)
20mg
Approved Conditions
Treatment of anorexia associated with weight loss in
patients with AIDs, chemotherapy/radiation therapy.
Palliative treatment of breast and endometrial carcinoma
Adjunctive therapy to promote weight gain after weight
loss following severe trauma and chronic infection
Treatment of anorexia associated with weight loss in patients with
AIDs, chemotherapy/radiation therapy. Treatment of nausea and
vomiting associated with cancer chemotherapy.
Authorization
Diagnosis:______________________________________________________________________
Previous therapy/dates:____________________________________________________________
Dosing schedule requested:_________________________________________________________
Additional comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________
The purpose of this record is for payment purposes. The patient’s medical record must substantiate the information provided on this form and compare
for consistency. Medicaid reserves the right to request chart records to confirm the information provided above
Practitioner Signature: _____________________________________________________________________________________
Date: _____________________________________________________________________________________________________
Revised 11/07/2014