U.S. Doctors Resources, L.L.C.
PRIOR AUTHORIZATION
DRUG THERAPY: Solodyn® (minocycline ER)_______Dynacin® (minocycline)
Orecea® (doxycycline) _______Actilate® (tetracycline)
_______Minocin® (micocycline)_______
Vibramycin® (doxycycline monohydrate) | |
DISEASE
MEDICAL REVIEW and DECISION:
The Prior Authorization for this medication has been denied. Further review is pending as:
Minocycline 100mg is Provided Free of Deductible.
1. There is no superiority of any individual tetracycline preparation for
Acne[1], therefore, minocycline or generic tetracycline[2] are approved by the Benefit Manager. Record symptoms initially and at 3-months in non-critical patients.
2. Refer to the Benefit Manager’s designated physician or his designee for
_____
a. Alternative Pricing if available
_____
b. Second Opinion alternative treatments for acne[2] starting with Pro-Active(TM) and over-the-counter preparations.
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. Physician Desk Reference
2.
http://www.ncbi.nlm.nih.gov/pubmed/12535427: Cochrane Database Syst Rev. 2003;(1):CD002086. Minocycline for acne vulgaris: efficacy and safety.
Garner SE1, Eady EA, Popescu C, Newton J, Li WA.
Signed b.n.r. Benefit Manager ___________________________________ date:__________
Copyrighted® 2016
