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

PRIOR AUTHORIZATION

DRUG THERAPY:

Tecfidera® (dimethyl fumarate)

DISEASE

Multiple Sclerosis

MEDICAL REVIEW and DECISION:

The Prior Authorization for this medication has been denied. Further review is pending as:

The pharmaceutical drug has not proven to be effective.

1. There is no superiority of commercial preparations[1] of this treatment for the pain[1] or spasticity[2] from Multiple Sclerosis, therefore, low dose naltrextone is approved by the Benefit Manager for an Alternative/ Complementary Protocol Trial. Record symptoms initially and at 3-months in non-critical patients.

2. The Canadian oral spray product, Sativex®[3], is approved by the government for the treatment of spasticity with Multiple Sclerosis. Available in Canada.

3. Contact Benefit Manager for Referral for an Alternative Protocol for adult sufferers.

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/12804404: Cochrane Database Syst Rev. 2002;(4):CD001330.Aminopyridines for symptomatic treatment in multiple sclerosis. Solari A1, Uitdehaag B, Giuliani G, Pucci E, Taus C.

2. http://www.ncbi.nlm.nih.gov/pubmed/18728058: A pilot trial of low-dose naltrexone in primary progressive multiple sclerosis. Gironi M1, Martinelli-Boneschi F, Sacerdote P, Solaro C, Zaffaroni M, Cavarretta R, Moiola L, Bucello S, Radaelli M, Pilato V, Rodegher M, Cursi M, Franchi S, Martinelli V, Nemni R, Comi G, Martino G.

3. Sativex


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


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