Immune Globulin Therapy Medication Precertification ...

1 GR-68305 (11-21)Continued on next page Page 1 of 6 Immunoglobulins Therapy Medication and/or Infusion Precertification request aetna Precertification notification Phone: 1-866-752-7021 FAX: 1-888-267-3277 For Medicare Advantage Part B: Please Use Medicare request Form (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment:Start date / / Continuation of Therapy :Date of last treatment / / Precertification Requested By: Phone:Fax:A. PATIENT INFORMATIONF irst Name: Last Name: Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: DOB: Al lergies: Email: Current Weight: lbsorkgsHeight: inches orcms B.

2 INSURANCE INFORMATIONA etna Member ID #: Group #: Insured: Does patient have other coverage? Yes NoIf yes, provide ID#: Carrier Name: Insured: Medicare: Yes No If yes, provide ID #: Medicaid: Yes No If yes, provide ID #: C. PRESCRIBER INFORMATIONF irst Name:Last Name: (Check One) Address: City: State: ZIP: Phone: Fax: St Lic #: NPI #: DEA #: UPIN: Provider Email: Office Contact Name: Phone: Specialty(Check one): OncologistHematologist Other:D. DISPENSING PROVIDER/ADMINISTRATION INFORMATIONP lace of Administration: Self-administered Physician s Office Outpatient Infusion Center Phone: Center Name: Home Infusion Center Phone: Agency Name: Administration code(s)(CPT): Address: Dispensing Provider/Pharmacy: Patient Selected choice Physician s Office Retail Pharmacy Specialty Pharmacy Other Other: Name: Address: Phone: Fax: TIN: PIN: E.

3 PRODUCT INFORMATIONR equest is for: Asceniv Bivigam Carimune NF Cutaquig Cuvitru Flebogamma DIF Hizentra HyQvia GamaSTAN GamaSTAN S/D Gammagard Liquid Gammagard S/D Gammaked Gammaplex Gamunex-C Octagam Panzyga Privigen Xembify Dose: Frequency:F. DIAGNOSIS INFORMATION Please indicate primary ICD Code and specify any other where ICD Code: Secondary ICD Code: Other ICD Code: G. CLINICAL INFORMATION Required clinical information must be completed in its entirety for all Precertification All Requests (EXCEPT GamaSTAN and GamaSTAN S/D, refer to page six for GamaSTAN and GamaSTAN requests) (clinical documentationrequired for all requests): Has the patient received immunoglobulin Therapy for a requested indication within the last 3 months?

4 Yes No Is this infusion request in an outpatient hospital setting? Yes Is this request to continue previously established treatment with the requested Medication ? YesPlease select the continuation request : This is a continuation of an existing treatment This is a continuation request , however a gap in Therapy of greater than 8 weeks has occurred NoPlease explain: This is a new Therapy request (patient has not received requested Medication in the last 6 months) This is a request for a different brand Immune Globulin product that the patient has not received previously Does the patient have laboratory confirmed autoantibodies to immunoglobulin A?

5 Yes No Has the patient experienced an adverse event with the requested product that has not responded to conventional interventions ( , acetaminophen, steroids, diphenhydramine, fluids, other pre-medications or slowing of infusion rate) or a severe adverse event (anaphylaxis, anaphylactoid reactions, myocardial infarction, thromboembolism, or seizures) during or immediately after an infusion? Yes No Does the patient have severe venous access issues that require the use of special interventions only available in the outpatient setting?

6 Hospital Yes No Does the patient have significant behavioral issues and/or physical or cognitive impairment that would impact the safety of the infusion Therapy AND the patient does not have access to a caregiver? YesPlease provide a description of the behavioral issue or impairment: No No GR-68305 (11-21) Continued on next pageImmunoglobulins Therapy Medication and/or Infusion Precertification request Page 2 of 6(All fields must be completed and legible for Precertification Review.)

7 aetna Precertification notification Phone: 1-866-752-7021 FAX: 1-888-267-3277 For Medicare Advantage Part B: Please Use Medicare request Form Patient First Name Patient Last Name Patient Phone Patient DOB G. CLINICAL INFORMATION (continued) Required clinical information must be completed in its entirety for all Precertification the patient medically unstable which may include respiratory, cardiovascular, or renal conditions that may limit the member s ability to tolerate a large volume or load or predispose the member to a severe adverse event that cannot be managed in an alternate setting without appropriate medical personnel and equipment?

8 Yes Please provide a description of the condition: Cardiovascular: Respiratory: Renal: No For Initiation requests (EXCEPT GamaSTAN and GamaSTAN S/D, refer to page six for GamaSTAN and GamaSTAN requests) (clinical documentation required for all requests): Acquired red cell aplasia Acute disseminated encephalomyelitis Has the patient had an insufficient response or contraindication to intravenous corticosteroid treatment? Yes No Autoimmune hemolytic anemia Which type of autoimmune hemolytic anemia does the patient have?

9 Warm type cold type other Has the patient tried corticosteroids with inadequate response? Yes No Has the patient had a splenectomy with inadequate response? Yes No Does the patient have a contraindication to corticosteroids or splenectomy? Yes No Autoimmune mucocutaneous blistering diseases Please select which applies to the patient: Bullous pemphigoid Epidermolysis bullosa acquisita Pemphigus vulgaris Mucous membrane pemphigoid Pemphigus foliaceus Other,please explain: Has the diagnosis been proven by biopsy and confirmed by pathology report?

10 Yes No Is the condition rapidly progressing, extensive, or debilitating? Yes No Has the patient failed or experienced significant complications ( , diabetes, steroid-induced osteoporosis) from standard treatment (corticosteroids, immunosuppressive agents)? Yes No Autoimmune neutropenia Is treatment with G-CSF (granulocyte colony stimulating factor) an appropriate option? Examples of G-CSF include Fulphila, Granix, Leukine, Neulasta, Neupogen, Udenyca, Zarxio. Yes No B-cell chronic lymphocytic leukemia (CLL)Please provide the patient s pre-treatment IgG level: Is IG prescribed for prophylaxis of bacterial infections?