Inflectra® (infliximab-dyyb) Injectable Medication ...

1 // /// / / / / / // / / Inflectra ( infliximab - dyyb ) Injectable Medication precertification request Aetna precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 For Medicare Advantage Part B: FAX: 1-844-268-7263 Page 1 of 4 (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.

2 PATIENT INFORMATION First Name: Last Name: Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: DOB: Allergies: Email: Current Weight: lbs orkgs Height:inches or cms B. INSURANCE INFORMATION Aetna Member ID #: Group #: Insured: Does patient have other coverage? YesNo If yes, provide ID#: Carrier Name: Insured: Medicare: Yes No If yes, provide ID #: Medicaid: YesNoIf yes, provide ID #: C. PRESCRIBER INFORMATION First 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):Dermatologist Gastroenterologist Rheumatologist Other: D.

3 DISPENSING PROVIDER/ADMINISTRATION INFORMATION Place 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 Mail Order Other: Name: Address: Phone: Fax:TIN: PIN:E. PRODUCT INFORMATION Please select the Medication being requested request is for: Inflectra ( infliximab - dyyb ) Dose: Frequency: F.

4 DIAGNOSIS INFORMATION Please indicateprimary ICD Code and specify any other where applicable. Primary ICD Code: Secondary ICD Code: Other ICD Code: G. CLINICAL INFORMATION Required clinical information must be completed in its entirety for all precertification requests. For Initiation Requests (Clinical documentation required for all reques ts): Will infliximab - dyyb (Inflectra) be used concomitantly with apremilast, tofacitinib, or other biologic DMARDs ( , adalimumab, certolizumab)? Yes No Does the patient have a documented TB test within 6 months of initiating a biologic therapy?

5 Yes(check all that apply):PPD test interferon-gamma assay (IGRA) chest x-rayPlease enter the date and results of the TB test:Date: / / Results:Positive Negative Unknown If positive, Does the patient have latent or active TB?Latent ActiveIf latent TB,Will TB treatment be started before initiation of therapy with infliximab - dyyb (Inflectra)? YesNo NoIs this infusion request in an outpatient hospital setting? Yes Is the patient medically unstable for infusions at alternate levels of care?YesNo No Does the patient have a history of any cardiopulmonary conditions?

6 YesPlease provide the description of the condition: Does this condition cause an increased risk of severe adverse reactions? Yes No NoDoes the patient have documentation of unstable vascular access?Yes NoDoes the patient have physical or cognitive impairments such that home infusion would present an unnecessary health risk? Yes Please explain: NoIs there clinical evidence that the patient has an inability to safely tolerate intravenous volume load (including from unstable renal function)? YesIs the inability to tolerate intravenous volume load due to unstable renal function?

7 YesPlease document the following: GFR:mL/ Collected:BUNmg/dLDate Collected: Creatinine: mg/dLDate Collected: No NoAnkylosing Spondylitis and other spondyloarthropathiesPlease select which of the following applies to the patient? ankylosing spondylitis other spondylarthropathyIs there evidence that the disease is active? Yes No Is there evidence of the inflammatory disease? Yes NoHas the patient had an inadequate response to two or more non-steroidal anti-inflammatory drugs (NSAIDs)? YesPlease provide the names and date ranges:NSAID #1: Date range: to NSAID #2:Date range: to NoContinued on next page GR-69299 (1-18) Aetna precertification Notification Inflectra ( infliximab - dyyb ) Injectable 503 Sunport Lane, Orlando, FL 32809 Medication precertification request Phone: 1-866-503-0857 FAX: 1-888-267-3277 Page 2 of 4 (All fields must be completed and legible for precertification Review.)

8 For Medicare Advantage Part B: FAX: 1-844-268-7263 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 requests. Behcet s Uveitis Does the patient have clinical evidence of Behcet s uveitis? Yes NoIs there evidence that the disease is refractory? Yes No Crohn s Disease Does the patient have fistulizing Crohn s disease? Yes How long has the patient had fistulizing Crohn s disease?

9 Less than 3 months3 months or longer NoWhat is the severity of the patient s Crohn s disease?Mild Moderate SevereDoes the patient have a documented diagnosis of active Crohn s disease? YesIf yes, check all signs/ symptoms that apply: abdominal pain arthritis bleeding diarrhea internal fistulae intestinal obstructionmegacolonperianal diseasespondylitisweight lossNone of the aboveHas the Crohn s disease symptoms remained active despite treatment with either 6-mercaptopurine, azathioprine, or corticosteroids? YesPlease check all medications that apply: 6-mercaptopurine azathioprinecorticosteroidsPlease provide: Name: Date range: to No No/ / / / EnterocolitisIs there clinical evidence the patient has severe or life-threatening enterocolitis?

10 YesPlease select which of the following symptoms the patient exhibits: 7 or more stools per day above baseline ileusfever None NoDid the patient develop enterocolitis while receiving Yervoy or Opdivo? Yes NoHas the enterocolitis persisted despite permanent discontinuation of Yervoy or Opdivo?Yes NoWas the patient treated with systemic corticosteroids?Yes NoHas the enterocolitis persisted despite administration of systemic corticosteroids?Yes NoHidradenitis suppurativa Please indicate the stage of hidradenitis suppurativa: Hurley stage I (mild disease) Hurley stage II (moderate disease) Hurley stage III (severe disease) UnknownHas the patient completed a 90 day trial of antibiotics?