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

PRIOR AUTHORIZATION

DRUG THERAPY:

Stelara® / ustekinumab

DISEASE

Plaque Psoriasis

MEDICAL REVIEW and DECISION:

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

Alternate treatments with less severe side effects are available first.

Record symptoms initially and at 3-months in non-critical patients to document the need for Stellara® drug medication.

1. Alternate treatments with less severe side effects are available first.
   (a.) High dose (5000mg) krill oil been shown to be effective.[1]
   (b.) Topical Naltrexone 1% may reduce the itching (pruiritis).[2]
Record symptoms initially and at 3-months in non-critical patients to document the need for Stellara® drug medication.

2. Contact Benefit Manager for Compounding Pharmacy.

3. Contact Benefit Manager for Second Opinion for Complementary/ Alternative Protocols.

With the addition of (1.), (2.) and (3.), the employee/ dependent may continue the Stellara® 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/21034986: Clin Dermatol. 2010 Nov-Dec;28(6):615-26. doi: 10.1016/j.clindermatol.2010.03.027. Nutrition and psoriasis. Ricketts JR1, Rothe MJ, Grant-Kels JM.

2. http://www.ncbi.nlm.nih.gov/pubmed/17320241: Cochrane Database Syst Rev. 2010 Dec 8;(12):J Am Acad Dermatol. 2007 Jun;56(6):979-88. Epub 2007 Feb 22. Treatment of pruritus with topically applied opiate receptor antagonist. Bigliardi PL1, Stammer H, Jost G, Rufli T, Büchner S, Bigliardi-Qi M.

3. http://www.ncbi.nlm.nih.gov/pubmed/21660442: Arch Dermatol Res. 2011 Aug;303(6):417-24. doi: 10.1007/s00403-011-1157-5. Epub 2011 Jun 10. Changes in the sex hormone profile of male patients with moderate-to-severe plaque-type psoriasis under systemic therapy: results of a prospective longitudinal pilot study. Boehncke S1, Salgo R, Garbaraviciene J, Beschmann H, Ackermann H, Boehncke WH, Ochsendorf FR.



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