Infliximab (Remicade ) Injectable Medication Precertification Request

Infliximab (Remicade®) Injectable
Medication Precertification Request
Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
Page 1 of 2
(Please complete all fields and return both pages for precertification review)
Please indicate:
Start of treatment: Start date
Precertification Requested By:
A. PATIENT INFORMATION
First Name:
Address:
Home Phone:
Current Weight:
lbs or
B. INSURANCE INFORMATION
/
Yes
Continuation of therapy: Date of last treatment
Phone:
Work Phone:
kgs Height:
Does patient have other coverage?
If yes, provide ID#:
Insured:
No If yes, provide ID #:
Medicaid:
C. PRESCRIBER INFORMATION
First Name:
Address:
Phone:
Fax:
Provider Email:
Specialty (Check one):
Dermatologist
Last Name:
City:
St Lic #:
Office Contact Name:
Gastroenterologist
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
Place of Administration:
Self-administered
Physican’s Office
Outpatient Infusion Center
Phone:
Center Name:
Home Infusion Center
Phone:
Agency Name:
Administration code(s) (CPT):
DOB:
State:
Email:
Cell Phone:
cms
Allergies:
inches or
/
ZIP:
Yes
No
Carrier Name:
Yes
No If yes, provide ID #:
(Circle one): M.D. D.O. N.P. P.A.
State:
ZIP:
DEA #:
UPIN:
Phone:
NPI #:
Rheumatologist
/
Fax:
Last Name:
City:
Aetna Member ID #:
Group #:
Insured:
Medicare:
/
Other:
Dispensing Provider/Pharmacy: (Patient selected choice)
Physician’s Office
Retail Pharmacy
Specialty Pharmacy
Mail Order
Other:
Name:
Phone:
TIN:
Fax:
PIN:
E. PRODUCT INFORMATION
Request is for Remicade: Dose:
Frequency:
F. DIAGNOSIS INFORMATION - Please indicate primary ICD-9 code and specify any other where applicable.
Primary ICD-9:
Other:
G. CLINICAL INFORMATION - Required clinical information must be completed completed in its entirety for all precertification requests.
Crohn’s Disease
Yes
No
Does the patient have active Crohn’s disease manifested by:
abdominal pain
arthritis
bleeding
diarrhea
internal fistulae
intestinal obstruction
If yes, check all that apply:
megacolon
perianal disease
spondylitis
weight loss
Yes
No
Has the Crohn’s disease remained active despite treatment with 6-mercaptopurine, azathioprine or corticosteroids?
Yes
No
Does the patient have fistulizing Crohn’s disease?
Yes
No
Has the fistulizing Crohn’s disease been active for at least 3 months?
Ulcerative Colitis
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
Is the patient hospitalized with fulminant ulcerative colitis?
Does the patient have moderately to severely active ulcerative colitis?
Is the patient refractory to or require continuous immunosuppression with corticosteroids (e.g., methylprednisolone, prednisone) at a dose
of prednisone 40 to 60 mg/day (or equivalent) for 30 days for oral therapy or 7 to 10 days for IV therapy?
Is the patient refractory to or have a contraindication to 5-aminosalicylic acid agents (e.g., balsalazide, mesalamine, sulfasalazine)?
Is the patient refractory to or have a contraindication to immunosuppressants (e.g., 6-mercaptopurine or azathioprine)?
Psoriasis
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Does the patient have moderate to severe chronic plaque psoriasis?
Is the patient a candidate for systemic therapy or phototherapy?
Does the plaque psoriasis affect 10% or more of the body surface area?
Does the plaque psoriasis affect 5% or more of the body surface area involving sensitive areas such as the hands, feet, face, or genitals?
Does the patient have a Psoriasis Area and Severity Index (PASI) score of 10 or more?
In correspondence to the current psoriasis flare or treatment request has the patient failed to adequately respond to or was the patient
intolerant to a 3-month trial of one of the following phototherapies listed below?
If yes, check all that apply:
Psoralens (methoxsalen, trioxsalen) with UVA light (PUVA)
UVB with coal tar or dithranol
UVB (standard or narrow-band)
Contraindicated: Please explain:
FOR CONTINUATION OF THERAPY:
Yes
No
Has the patient failed to adequately respond to 12 weeks of infliximab (Remicade) treatment?
GR-68855 (10-13)
Infliximab (Remicade®) Injectable
Medication Precertification Request
Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
Page 2 of 2
(Please complete all fields and return both pages for precertification review)
Patient First Name
Patient Last Name
Patient Phone
Patient DOB
H. CLINICAL INFORMATION Section 2 - Required clinical information must be completed in its entirety for allprecertification requests.
Psoriatic Arthritis
Yes
No
Does the patient have moderately to severely active psoriatic arthritis?
Yes
No
Has the patient had an inadequate response to non-biologic disease-modifying anti-rheumatic drugs (DMARDs)?
azathioprine
cyclosporine
leflunomide
methotrexate
sulfasalazine
Other:
If yes, check ALL that apply:
Rheumatoid Arthritis
Yes
No
Does the patient have moderately to severely active rheumatoid arthritis?
Yes
No
Will the patient be using infliximab (Remicade) in combination with methotrexate?
If no, please explain why:
Juvenile Idiopathic Arthritis
Yes
No
Does the patient have moderately to severely active polyarticular juvenile idiopathic arthritis?
Yes
No
Does the patient have a contraindication, intolerance, or incomplete response to etanercept (Enbrel) AND adalimumab (Humira)?
Reactive Arthritis or Inflammatory Bowel Disease Arthritis
Yes
No
Does the patient have refractory reactive arthritis or inflammatory bowel disease arthritis (enteropathic arthritis)?
Yes
No
Has the patient failed or been intolerant to methotrexate?
Yes
No
Has the patient failed or been intolerant to sulfasalazine?
Yes
No
Has the patient failed or been intolerant to non-steroidal anti-inflammatory drugs (NSAIDs)?
Spondylitis
Yes
No
Does the patient have active ankylosing spondylitis or other active spondyloarthropathy with evidence of inflammatory disease?
Yes
No
Has the patient had an inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs)?
celecoxib
diclofenac
ibuprofen
indomethacin
meloxicam
naproxen
sulindac
If yes, check ALL that apply:
Other
Chronic Pulmonary Sarcoidosis
Yes
No
Does the patient remain symptomatic despite treatment for 3 or more months with both steroids AND immunosuppressants?
Yes
No
Was the steroid dose 10mg per day or more?
Pyoderma Gangrenosum
Yes
No
Does the patient have refractory pyoderma gangrenosum?
Uveitis
Yes
No
Does the patient have refractory Bechet’s uveitis?
Hidradinitis suppurativa
Yes
No
Does the patient have severe disease refractory to systemic antibiotics?
I. ACKNOWLEDGEMENT
Request Completed By (Signature Required):
Date:
/
/
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive any
insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.
GR-68855 (10-13)