Proleukin (aldesleukin) prior authorization for Florida Medicaid
Defines prior authorization requirements for Proleukin (aldesleukin) for Florida Medicaid recipients, including required documentation, eligible indications, and maximum approval length; applies to prescribers and pharmacies submitting PA requests to Florida Medicaid.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Authorization Criteria
Covered when ALL of the following are met:
Provider must retain copies of all documentation for five years and fax the completed form to 1-866-940-7328.
This policy defines the prior authorization requirements for Proleukin (aldesleukin) for Florida Medicaid. Coverage is available when the Proleukin PA form is completed in full and submitted with the required clinical documentation supporting one of the approved indications and the requested dosing/frequency. The PA form notes a maximum length of therapy of three months and requires retention of supporting documentation for five years.
The Proleukin PA form must be completed in full before submission. An incomplete form may be returned, which can delay review and may result in denial if required information or supporting medical records and labs are missing.
Coding
| 49031 | Generic Code |
Provider Actions & Authorization
Prior Authorization Required
Prior authorization is required for Proleukin (interleukin-2) through the Florida Medicaid Proleukin PA form. Submit the completed PA form to the Pharmacy PA Call Center (fax 1-866-940-7328). Approval, when granted, is for a maximum length of three months.
- Fax PA form: 1-866-940-7328
- Pharmacy PA Call Center: 1-800-310-6826
Provider Actions
Providers should complete the Florida Medicaid Proleukin PA form in full and ensure dosage and frequency are documented. An incomplete form may be returned and delay review.
- Include prescriber name, NPI, phone and fax
- Specify diagnosis and dosing schedule
- Prescriber signature and date required
Required Documentation for Review
Required documentation for review includes the completed Florida Medicaid PA form plus all relevant medical records. Retain copies of all documentation for five years.
- Completed Florida Medicaid Proleukin PA form
- Diagnostic evaluations and recent chart notes
- Most recent related laboratory results
- Any supporting clinical materials
Incomplete Documentation May Delay or Prevent Approval
An incomplete PA form or missing supporting records (e.g., labs, chart notes) may be returned or result in denial/non-approval. Ensure all requested fields on the PA form are completed to avoid processing delays.
- Incomplete form may be returned
- Missing labs or clinical records can prevent approval
Definitions
Background
Proleukin (aldesleukin) is listed on the Florida Medicaid PA form for treatment of select malignancies. The form identifies the approved indications as renal cell carcinoma, metastatic melanoma, non-Hodgkin's lymphoma, and acute myelogenous leukemia, and requests the diagnosis, dosage and frequency, and supporting medical records and most recent related labs. The PA form instructs providers to fax the completed form for review and notes that approval is granted for a maximum of three months.
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