Remicade® (infliximab) Injectable Medication ...

1 GR-68855 (2-22)Remicade ( infliximab ) Injectable Medication precertification request Page 1 of 8 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: E-mail:Current Weight:lbsorkgsHeight:inchesorcmsAllergi es: B. 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.

2 PRESCRIBER INFORMATIONF irst Name:Last Name: (Check One): Address:City:State:ZIP:Phone: Fax: St Lic #: NPI #: DEA #: UPIN: Provider E-mail: Office Contact Name: Phone: Specialty (Check one):Dermatologist Gastroenterologist Rheumatologist Other:D. DISPENSING PROVIDER/ADMINISTRATION INFORMATIONP lace of Administration: Self-administered Physician s Office Outpatient Infusion CenterPhone: Center Name: Home Infusion CenterPhone: Agency Name: Administration code(s) (CPT): Address: Dispensing Provider/Pharmacy:Patient Selected choice Physician s Office Retail Pharmacy Specialty Pharmacy OtherName:Address: Phone: Fax:TIN: PIN: E. PRODUCT INFORMATIONR equest is for: Remicade ( infliximab )Dose:Frequency:F. DIAGNOSIS INFORMATION Please indicate primary ICD Code and specify any other where ICD Code: Secondary ICD Code:Other ICD Code: G.

3 CLINICAL INFORMATION Required clinical information must be completed in its entirety for all precertification All Requests (clinical documentation required for all requests): Will the requested drug be used in combination with any other biologic ( , Humira) or targeted synthetic disease-modifying anti-rheumatic drug (DMARD) ( , Olumiant, Otezla, Xeljanz)? Yes No Has the patient ever received (including current utilizers) a biologic ( , Humira) or targeted synthetic DMARD ( , Olumiant, Xeljanz) associated with an increased risk of tuberculosis (TB)? Yes NoHas the patient had a tuberculosis (TB) test ( , tuberculosis skin test [PPD], interferon-release assay [IGRA], chest x-ray) within 6 months of initiating therapy? Yes (Check all that apply): PPD test interferon-gamma assay (IGRA) chest x-ray Please enter the results of the tuberculosis (TB) test: positive negative unknown If positive, please indicate which applies to the patient: latent TB and treatment for latent TB has been initiated latent TB and treatment for latent TB has been completed latent TB and treatment for latent TB has not been initiated active TB NoContinued on next page GR-68855 (2-22)Remicade ( infliximab ) Injectable Medication precertification request Page 2 of 8(All fields must be completed and legible for precertification review.)

4 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 Is this infusion request in an outpatient hospital setting?G. CLINICAL INFORMATION (continued) Required clinical information must be completed in its entirety for all precertification requests. YesHas 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 NoHas the patient developed antibodies to infliximab which increases the risk for infusion related reactions?

5 Yes NoDoes the patient have severe venous access issues that require the use of special interventions only available in the outpatient hospital setting? Yes NoDoes 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 Is 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? Yes Please provide a description of the condition:Cardiopulmonary: Respiratory: Renal: Other: No NoFor Initiation Requests (clinical documentation required for all requests): Acute graft versus host disease Is the requested quantity supported by dosing guidelines found in the compendia or current literature ( , Micromedex DrugDex, NCCN compendia, current treatment guidelines)?

6 Yes No Has the patient experienced an inadequate response to systemic corticosteroids? Yes NoDoes the patient have an intolerance or contraindication to corticosteroids? Yes NoAnkylosing spondylitis and axial spondyloarthritis Please indicate loading dose at weeks 0, 2 and 6: _____Please indicate maintenance dose: ____frequency: _____weeks Please select which of the following applies to the patient: Active ankylosing spondylitis (AS) Active axial spondyloarthritis _____Has the patient ever received (including current utilizers) a biologic ( , Cimzia) indicated for active ankylosing spondylitis or active axial spondyloarthritis? Yes No Has the patient experienced an inadequate response with at least TWO nonsteroidal anti-inflammatory drugs (NSAIDs), or has an intolerance or contraindication to at least two NSAIDs? Yes NoPlease indicate the preferred alternatives for ankylosing spondylitis (AS) or axial spondyloarthritis that have been ineffective, not tolerated, or are contraindicated: Cosentyx Enbrel Humira Simponi AriaHas the patient tried and failed treatment with Inflectra ( infliximab -dyyb) due to a documented intolerable adverse event ( , rash, nausea,vomiting)?

7 YesWas the adverse event unexpected and not attributed to the active ingredient as described in the prescribing information ( , known adverse reaction for both the brand and biosimilar Medication )? Yes No NoBeh et s disease Is the requested quantity supported by dosing guidelines found in the compendia or current literature ( , Micromedex DrugDex, NCCN compendia, current treatment guidelines)? Yes No Has the patient ever received (including current utilizers) Otezla or a biologic ( , Humira) indicated for the treatment of Beh et s disease? Yes No Has the patient had an inadequate response to at least one nonbiologic Medication for Beh et s disease ( , apremilast, colchicine, systemic glucocorticoids, azathioprine)? Yes NoCrohn s diseasePlease indicate loading dose at weeks 0, 2 and 6: Please indicate maintenance dose: _____frequency:_____weeks _____ Is the requested quantity supported by dosing guidelines found in the compendia or current literature ( , Micromedex DrugDex, NCCN compendia, current treatment guidelines)?

8 YesPlease select: Supported by the manufacturer s prescribing information Is the requested dose and frequency supported by the manufacturer s prescribing information for the patient s diagnosis? Yes No Supported by dosing guidelines found in the compendia or current literature Is the supporting information attached? Yes No No Has the patient been diagnosed with moderately to severely active Crohn s disease (CD)? Yes No Has the patient ever received (including current utilizers) a biologic ( , Humira) indicated for moderately to severely active Crohn s disease? Yes No Does the patient have fistulizing Crohn s disease? Yes No Has the patient tried and had an inadequate response to at least one conventional therapy option? Yes Please select: Sulfasalazine (Azulfidine, Sulfazine) Metronidazole (Flagyl) Ciprofloxacin (Cipro) Prednisone Budesonide (Entocort EC) Azathioprine (Azasan, Imuran) Mercaptopurine (Purinethol) Methotrexate IM or SQ Methylprednisolone (Solu-Medrol) Rifaximin (Xifaxan) Tacrolimus NoDoes the patient have a contraindication or intolerance to at least one conventional therapy option ( , azathioprine [Azasan, Imuran], budesonide [Entocort EC], ciprofloxacin [Cipro], mercaptopurine [Purinethol], methylprednisolone [Solu-Medrol], methotrexate IM or SC, metronidazole [Flagyl], prednisone, sulfasalazine [Azulfidine, Sulfazine], rifaximin [Xifaxan], tacrolimus)?

9 Yes NoContinued on next page GR-68855 (2-22)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. Please indicate t he preferred alternatives for Crohn s disease that have been ineffective, not tolerated, or are contraindicated: Humira Entyvio Stelara (intravenous formulation) Has the patient tried and failed treatment with Inflectra ( infliximab -dyyb) due to a documented intolerable adverse event ( , rash, nausea,vomiting)? Yes Was the adverse event unexpected and not attributed to the active ingredient as described in the prescribing information ( ,known adverse reaction for both the brand and biosimilar Medication )? Yes No No Granulomatosis with polyangiitis (Wegener s granulomatosis) Is the requested quantity supported by dosing guidelines found in the compendia or current literature ( , Micromedex DrugDex, NCCN compendia, current treatment guidelines)?

10 Yes No Has the patient experienced an inadequate response with corticosteroids or immunosuppressive therapy ( , cyclophosphamide, azathioprine, methotrexate, mycophenolate mofetil)? Yes NoHas the patient experienced an intolerance to corticosteroids and immunosuppressive therapy ( , cyclophosphamide,azathioprine, methotrexate, mycophenolate mofetil)? Yes No Does the patient have a contraindication to corticosteroids and immunosuppressive therapy ( , cyclophosphamide, azathioprine, methotrexate, mycophenolate mofetil)? Yes No Hidradenitis suppurativa Is the requested quantity supported by dosing guidelines found in the compendia or current literature ( , Micromedex DrugDex, NCCN compendia, current treatment guidelines)? Yes No Has the patient been diagnosed with severe, refractory hidradenitis suppurativa? Yes NoHas the patient ever received (including current utilizers) a biologic ( , Humira) indicated for the treatment of severe, refractory hidradenitis suppurativa?