U.S. Doctors Resources, L.L.C.

PRIOR AUTHORIZATION

DRUG THERAPY:

Dihydroergotamine DHE-45®

DISEASE

Migraine

MEDICAL REVIEW and DECISION:

The Prior Authorization for the above drug has been denied pending the following:
    Alternative pricing for Nasal Medication is Available Free of Deductible.
Consultation is available to evaluate the hormonal and mechanical influences of the migraine/ tension-type headache.

1. For migraine, specificially hormonal migraine in women and cluster headaches in men, preventative therapy in women with danazol[1] and testosterone pellets in men[2] are documented. BOTOX® may then be considered[3].

2. Contact Benefit Manager for Referral for Hormonal Prevention Protocols for adult sufferers.

3. Contact Benefit Manager for Referral for BOTOX® therapeutic trial.

Pending (1.), (2.) and (3.) the employee/ dependent may continue the medication as prescribed by the treating physician by attaching a valid 3-month prescription with up to 12-months of refills to the Cover Page and mailing it back to:

ATTN: Benefit Manager
City of Hazel Park Self-Insurance Health Program
111 East Nine Mile Road
Hazel Park, Michigan 48030


Please send the demographics about the patient that appear on the Cover Page of the Prior Authorization form and the Credit Card Information from the Flexible Spending Account in the boxes below.

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IDENTIFICATION:

Demographics		Health Insurance/ Credit Card
Member Name:	____________________________________	Member Name on the Card:	_____________________________________
Insurance ID:	____________________________________	Issuing Service:	VISA, MC, Discover _________________
Date of Birth:	____________________________________	Number:	____________________________________
Street Address:	____________________________________	Expiration:	____________________________________
City/ State/ Zip code:	____________________________________	CVV Code:	____________________________________
Telephone Number:	____________________________________
		Signature of Employee/ Insured:
		_________________________________
Signature of Treating Physician:	___________________________________

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References:
1. http://www.ncbi.nlm.nih.gov/pubmed/1865397: J Reprod Med. 1991 Jun;36(6):419-24. Efficacy of danazol in the control of hormonal migraine. Lichten EM, Bennett RS, Whitty AJ, Daoud Y.

2. http://www.ncbi.nlm.nih.gov/pubmed/16732838: Headache. 2006 Jun;46(6):925-33. Testosterone replacement therapy for treatment refractory cluster headache. Stillman MJ.

3. http://www.ncbi.nlm.nih.gov/pubmed/22468643 Drugs. 2012 Apr 16;72(6):825-45. doi: 10.2165/11208880-000000000-00000. Onabotulinumtoxin-A (BOTOX®): a review of its use in the prophylaxis of headaches in adults with chronic migraine. Frampton JE.


Benefit Manager:
Signed b.n.r.______________________________________     Date:_______________________


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