Form Chch 2033 1 PDF Details

In November of 2032, the residents of Christchurch and the Canterbury region were reeling from a series of earthquakes that had caused widespread damage. The final straw came when a powerful earthquake struck on November 13th, destroying much of the city center and killing 185 people. In response to this disaster, the government passed the Canterbury Earthquake Recovery Act (CERA) in January of 2033, which provided for the reconstruction of Christchurch. This act established the Canterbury Earthquake Recovery Authority (CERA) as the lead agency for reconstruction efforts. CERA was responsible for developing a plan for rebuilding Christchurch, coordinating funding and resources from both public and private sectors, and managing recovery projects. Today, we take a look back at how CERA performed in its first five years and what lessons can be learned from its successes and failures.

QuestionAnswer
Form NameForm Chch 2033 1
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesc054190 altius coventry form

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FIBROMYALGIA PRIOR AUTHORIZATION FORM

Coverage Policy: Lyrica, Cymbalta and Savella are covered for members with the diagnosis of fibromyalgia when ALL of the following criteria have been met. Other uses are not covered.

Documented failure* of the following:

1.ONE of the tricyclic antidepressants (TCA), AND

2.ONE of the muscle relaxants (e.g. cyclobenzaprine), AND

3.Documented non-pharmacologic therapies (cognitive behavioral therapies, exercise etc.), AND

4.At least TWO drugs from the following agents:

a.Any one SSRI, or

b.Tramadol, or

c.Gabapentin

*Failure is defined as intolerance or no clinical efficacy.

NON-covered uses are listed in the Prior Authorization criteria, which is available upon request.

>>>Requests for Lyrica or Cymbalta for diagnoses other than Fibromyalgia – please use the Lyrica or Cymbalta form <<<

PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE – PHARMACEUTICAL SERVICES

FAX:Q1 (866) 738-9682 PHONE: (877) 215- 4100

Requesting Physician:

 

Office Contact:

 

 

 

 

 

Call Center ID:

Tax ID Number:

Plan ID:

Benefit:

 

 

 

Office Fax Number:

 

Phone Number:

 

 

 

 

Office Address:

 

 

 

 

 

 

MEMBER INFORMATION

 

 

Patient Name:

 

DOB:

 

 

 

 

Member ID#:

 

Date of Request:

 

 

 

 

MEDICATION INFORMATION

1. DRUG REQUESTED:

O Cymbalta

O Savella

O Lyrica

Please list specific past treatment trials and submit progress notes related to the request:

OTCA Drug:_____________ Dates used: ________ Therapeutic Outcome: __________________________

OMuscle Relaxant

2.Drug:_____________ Dates used: ________ Therapeutic Outcome: __________________________

OSSRI Drug:_____________ Dates used: _______ Therapeutic Outcome: __________________________

O

Tramadol

Dates used: ________

Therapeutic Outcome: ________________________

O

Gabapentin

Dates used: _______

Therapeutic Outcome: __________________________

Did member fail non-pharmacologic therapy? YES O NO O

3.Therapy Tried:_____________________________________________________________________

_________________________________________________________________________________

Additional Comments:

4.

Physician’s Signature:

CHCH 2033-1 (2/09)

Visit our Website at WWW.CVTY.COM

Fax Confidentiality Notice: The information contained in this transmission is confidential, proprietary or privileged and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act (HIPAA). The message is intended for the sole use of the individual or entity to whom it is addressed. If you are not the intended recipient, you are notified that any use, distribution or copying of the attached material is strictly prohibited and may subject you to criminal or civil penalties. If you received this transmission in error please notify us immediately by telephone at 1-877-215-4100.

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