Prior Authorization Gocovri

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Enter Patient Information

  • Drug Name: *
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • ICD-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.
  • Has the patient been using samples?
  • Yes No
  • Dose and Directions: *

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Enter Provider Information

  • Provider ID OR NPI: *
  • Provider's Name: *
  • Physician's Specialty: *
  • Street Address: *
  • City: *
  • State: *
  • ZIP Code: *
  • Email Address:
  • Phone Number:
  • Enter a 10 digit phone number.
  • Fax Number:
  • Enter a 10 digit phone number.
  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address: *
  • Contact Phone Number: *
  • Contact Phone Ext:
  • Contact Fax Number: *

Drug Name/J-Code: *

Dyskinesia in Patients with Parkinson's Disease (PD).

Does patient meet ONE of the following? (A or B)

  • A. Initial Therapy. Does the patient meet the following criteria (i, ii, and iii):
  • Yes
  • No
  • i. Gocovri is prescribed by or in consultation with a neurologist; AND
  • Yes
  • No
  • ii. Patient is currently receiving levodopa-based therapy (e.g., carbidopa/levodopa); AND
  • Yes
  • No
  • iii. Patient has tried immediate-release amantadine capsules, tablets, or oral solution and meets ONE of the following criteria (a or b):
  • Yes
  • No
  • a) Patient derived benefit from IR amantadine but had intolerable adverse events, as determined by prescriber; OR *
  • Yes
  • No
  • b) Patient could not achieve a high enough dosage to gain adequate benefit, as determined by the prescriber. *
  • Yes
  • No
  • B. Patients Currently Receiving Gocovri. Does the patient meet the following criteria (i and ii):
  • Yes
  • No
  • i. Gocovri is prescribed by or in consultation with a neurologist; AND
  • Yes
  • No
  • ii. Patient is currently receiving levodopa-based therapy (e.g., carbidopa/levodopa); AND
    Patient has had a response to therapy (e.g., decrease in dyskinesia), as determined by the prescriber. *
  • Yes
  • No

PLEASE SEND PROGRESS NOTES

If you are using a Specialty Pharmacy, please indicate which one will be providing the medication. *

  • Accredo:
    Phone: 877-259-2295
    Fax: 888-773-7386
  • Other:
Select Accredo or Other
Select Other Specialty Pharmacy

If service is not in your office please list the Infusion site or Facility/list ordering physician.

If you have any additional information pertinent to this patient's therapy, please specify.

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Blue Cross and Blue Shield of Kansas City
Pharmacy Services
P.O. Box 412735
Kansas City, MO 64141-2735

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Revised 06/01/18

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