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PAxx Humira/ adalimumab


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

PRIOR AUTHORIZATION


DRUG THERAPY:

Humira® (adalimumab)


Disease

Ulcerative Colitis, Inflammatory Bowel Disease


MEDICAL REVIEW and DECISION:

The Prior Authorization for this medication has been denied. Further review is pending as:
_________________ Standard therapy with 5-ASA[1] and DMARDs[2] are effective.
_________________ Second opinion consultation/ hormonal review is mandated
__________________as potential replacement may be indicated in adults.[3]



1. For ulcerative colitis, the standard of therapy[1]
     (a). starts with aminosalicylates (such as 4-ASA mesalamine, olsalazine), salicylates (e.g., aspirin, salsalate), and 5-ASA sulfasalazine[2];
     (b). then may be followed by DMARDs[3].

2. Contact Benefit Manager for:
     (a.) Alternative pricing.
     (b.) Referral for Anabolic Protocol for adult sufferers. Case Reports confirm that specific low levels of bio-available hormones are often noted in Inflammatory Bowel Disease. The initial results of the hormonal treatment protocol are promising and without adalimumab side-effects.

Pending (1.) and (2.) 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.






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:___________________________________





References:
1. http://www.ncbi.nlm.nih.gov/pubmed/23076890 Cochrane Database Syst Rev. 2012 Oct 17;10:CD000544. doi: 10.1002/14651858.CD000544.pub3. Oral 5-aminosalicylic acid for maintenance of remission in ulcerative colitis. Feagan BG1, Macdonald JK.

2. http://www.ncbi.nlm.nih.gov/pubmed/9561342: Drugs. 1998 Apr;55(4):519-42. A practical guide to the management of distal ulcerative colitis. Ardizzone S1, Bianchi Porro G..

3. http://www.ncbi.nlm.nih.gov/pubmed/12014422: Int J Colorectal Dis. 2002 Mar;17(2):63-6.Association of dehydroepiandrosterone sulfate and testosterone deficiency with bone turnover in men with inflammatory bowel disease. Szathmári M1, Vásárhelyi B, Treszl A, Tulassay T, Tulassay Z.

4. https://www.ncbi.nlm.nih.gov/pubmed/23002356: World J Gastroenterol. 2012 Sep 21;18(35):4823-54. Use of the tumor necrosis factor-blockers for Crohn's disease. Thomson AB1, Gupta M, Freeman HJ.



Signed b.n.r. Benefit Manager ___________________________________ date:__________


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