Priority Health Medicare prior authorization form Fax completed form to: toll free, or

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1 Priority Health Medicare prior authorization form Fax completed form to: toll free, or This form applies to: Medicare Part B Medicare Part D This request is: Expedited request Standard request Your request will be expedited if you haven t gotten the prescription and Priority Health Medicare determines, or your prescriber tells us, that your life or health may be at risk by waiting. Remicade (infliximab) Member Last Name: First Name: ID #: DOB: Gender: Primary Care Physician: Requesting Physician: Phys. Phone: Phys. Fax: Physician Address: Physician NPI: Contact Name: Provider Signature: Product and Billing Information New Request Continuation Request Drug product: Remicade 100 mg vial Dose: Dose Frequency: Start date (or date of next dose): Date of last dose (if applicable): Date of last dose: Place of administration: Billing: Physician s office Outpatient infusion Facility: NPI: Fax: Home infusion Facility: NPI: Fax: Physician to buy and bill Facility to buy and bill Specialty Pharmacy Pharmacy: NPI: Fax: ICD-10 Diagnosis code(s): PriorityMedicare plans Note: Priority Health Medicare applies CMS national and local coverage determination criteria when available for Part B drugs. If no national determination criteria or local coverage determination criteria is available for the state in which the member is receiving the services, the above prior authorization criteria must be met. Page 1 of 5

2 WPS Medicare LCD L32013 This prior authorization form is based on local coverage determination (LCD) information obtained from the U.S. Department of Health & Human Services Center for Medicare & Medicaid Services (available and The primary jurisdiction for coverage outlined in this LCD is Michigan. For Priority Health Medicare members receiving this service outside the State of Michigan, please refer to the LCD for that state for coverage requirements. If no LCD is available for the state in which this service is being provided, coverage will be determined as outlined in this prior authorization document. Priority Health Precertification Documentation A. What is the patient s diagnosis? Behcet s Syndrome Colitis Ulcerative Colitis Active Crohn s disease Fistulizing Crohn s disease Plaque Psorisis Psoriatic arthritis Felty s syndrome Other rheumatoid arthritis with visceral or systemic involvement Juvenile chronic polyarthritis Ankylosing spondylitis Sarcoidosis Has the patient had a documented trial with both corticosteroid and immunosuppressant treatment?, rationale for use: Iridocyclitis Has the patient had a documented trial with immunosuppressive agents?, rationale for use: B. What is the result of the most recent annual TB test? Negative (test must be within the previous 12 months) Positive Test not done C. Does the patient have moderate to severe heart failure? No Yes rationale for use: Page 2 of 5

3 Priority Health Medicare prior authorization form Fax completed form to: toll free, or This form applies to: Medicare Part B Medicare Part D This request is: Expedited request Standard request Your request will be expedited if you haven t gotten the prescription and Priority Health Medicare determines, or your prescriber tells us, that your life or health may be at risk by waiting. Remicade (infliximab) Member Last Name: First Name: ID #: DOB: Gender: Primary Care Physician: Requesting Provider: Prov. Phone: Prov. Fax: Provider Address: Provider NPI: Contact Name: Provider Signature: Drug information Remicade 100 mg vial Dose: Dose Frequency: Start date: Date of last dose: Date of next dose: Prior authorization criteria The following requirements need to be met before this drug is covered by Priority Health Medicare. These requirements have been approved by the Centers for Medicare and Medicaid Services (CMS), but you may ask us for an exception if you believe one or more of these requirements should be waived. 1. Must be used for a medically-accepted indication* 2. Must have a negative TB test within the last 12 months (testing must be done yearly) 3. For certain diagnoses, additional criteria is required: Diagnosis Ankylosing spondylitis, plaque psoriasis, psoriatic arthritis Crohn s disease Ulcerative colitis Additional criteria required Trial and failure with either Enbrel or Humira Documented therapeutic trial and clinical failure with Humira Documented therapeutic trial of at least one DMARD AND either Enbrel or Humira Therapeutic trial of at least one of the following: aminosalicylates or steroids Additional information Note: Coverage is provided for 1 year per approved authorization Page 3 of 5

4 Medically accepted indication This drug is only covered under Medicare Part D when it is used for a medically accepted indication. A medically accepted indication is a use of the drug that is either: approved by the Food and Drug Administration. (That is, the Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.) or supported by certain reference books. (These reference books are the American Hospital Formulary Service Drug Information and the DRUGDEX Information System) Priority Health Precertification Documentation A. What is the date and result of the patient s last TB test? Negative Positive B. What condition is this drug being requested for? The patient s condition is: Ankylosing spondylitis Psoriatic arthritis Plaque psoriasis Additional information needed based on the patient s condition Which of the following drugs has the patient tried and failed? Enbrel Humira None of the above Crohn s disease Has the patient had a therapeutic trial and clinical failure with Humira? Which of the following drugs has the patient tried? non-biologic DMARD drug name: Enbrel Humira Ulcerative colitis Which of the following drugs has the patient tried? Aminosalicylates Corticosteroids None of the above Priority Health Medicare exception request Do you believe one or more of the prior authorization requirements should be waived? If yes, you must provide a statement explaining the medical reason why the exception should be approved. Would Remicade likely be the most effective option for this patient? If yes, please explain why: Page 4 of 5

5 If the patient is currently using Remicade, would changing the patient s current regimen likely result in adverse effects for the patient? If yes, please explain: Page 5 of 5