Pharmacy Prior Authorization
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- Luke Carter
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1 Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Mercy Care Plan at When conditions are met, we will authorize the coverage of Humira (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Humira (adalimumab) Other, specify drug Quantity Frequency Strength Route of administration Expected length of therapy Patient information Patient name: Patient ID: Patient Group o.: Patient DOB: Patient phone: Prescribing physician Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: Circle the appropriate answer for each question. Question Circle es or o 1. Has this plan authorized Humira in the past for this patient (i.e., previous authorization is on file under this plan)? [If no, skip to question 3.] 2. Has the patient shown improvement in signs and symptoms of disease? [o further questions.] 3. Does the patient have a diagnosis of moderate to severe active rheumatoid arthritis (RA) (e.g., swollen, tender joints with limited range of motion)? [If no, skip to question 6.] Reference umber: C4416-A / Effective Date: 06/01/2018 1
2 Circle es or o 4. Has the patient had an inadequate response to a three (3)-month trial of 2 different non-biologic DMARD regimens (1 of which must include methotrexate (MTX))? If yes, list medications tried: ote: Monotherapy regimen: methotrexate (MTX), leflunomide (LEF), or sulfasalazine (SSZ). Combination regimen: MTX+SSZ+hydroxychloroquine(HCQ); MTX+HCQ, MTX+LEF, MTX+SSZ, SSZ+HCQ 5. Did the patient have an intolerance to MTX, sulfasalazine (SSZ), or leflunomide (LEF) for 3 months or have a contraindication to MTX, sulfasalazine (SSZ), or leflunomide (LEF)? ote: Contraindications such as Pregnancy, alcoholism, Chronic liver disease, Leukopenia, thrombocytopenia, or anemia. If yes, please document contraindication: 6. Does the patient have a diagnosis of juvenile idiopathic arthritis (JIA)? [If no, skip to question 19.] 7. Does the patient have the systemic subtype of JIA? [If no, skip to question 11.] 8. Does the patient currently have any ACTIVE systemic features? ote: Systemic features such as fever, evanescent rash, lymphadenopathy, hepatomegaly, splenomegaly, or serositis. If yes, please list: [If yes, then no further questions.] 9. Does the patient continue to have synovitis in at least 1 joint despite 3 months of treatment with methotrexate or leflunomide? [If yes, skip to question 18.] Reference umber: C4416-A / Effective Date: 06/01/2018 2
3 Circle es or o 10.Does the patient have contraindications to methotrexate and leflunomide? ote: Contraindications such as Pregnancy, alcoholism, Chronic liver disease, Leukopenia, thrombocytopenia, or anemia. If yes, please document contraindication: [If yes, skip to question 18.] 11.Does the patient have severe or moderate to severe polyarticular juvenile idiopathic arthritis (pjia)? [If yes, skip to question 16.] 12.Does the patient have extended oligoarticular juvenile idiopathic arthritis (JIA)? 13.Has the patient tried and had inadequate response with at least 2 different SAIDs? If yes, please list medications tried: [If yes, skip to question 15.] 14.Does the patient have intolerable side effects with 2 SAIDs or contraindications to SAIDs? ote: Contraindications such as true allergic reaction to SAIDs, history of worsening asthma symptoms after taking aspirin or SAIDs, current GI bleed, severe renal dysfunction. If yes, please document contraindication: 15.Has the patient had an inadequate response or intolerable side effects with an adequate 3-month trial of MTX or has contraindications to MTX? [If yes, then skip to 18.] 16.Has the patient had an inadequate response to a three (3) months trial of methotrexate (MTX)? Reference umber: C4416-A / Effective Date: 06/01/2018 3
4 [If yes, skip to question 18.] Circle es or o 17.Did the patient have an intolerance to MTX, sulfasalazine (SSZ), or leflunomide (LEF) for 3 months or have a contraindication to MTX, sulfasalazine (SSZ), or leflunomide (LEF)? ote: Contraindications such as Pregnancy, alcoholism, Chronic liver disease, Leukopenia, thrombocytopenia, or anemia. If yes, please document contraindication: 18.Is the patient at least 2 years of age? [If no, no further questions.] [If yes, skip to question 61.] 19.Does the patient have a diagnosis of ankylosing spondylitis (AS)? [If no, skip to question 23.] 20.Did the patient have an inadequate response to a one (1) month trial of TWO non-steroidal anti-inflammatory drugs (SAIDS) at an adequate dose? If yes, please list medications tried: [If no, skip to question 22.] 21.Did the patient have an intolerance to TWO oral SAIDs? 22.Does the patient have contraindications to SAIDs? ote: Contraindications such as true allergic reaction to SAIDs, history of worsening asthma symptoms after taking aspirin or SAIDs, current GI bleed, severe renal dysfunction. If yes, please document contraindication: [If yes, then skip to question 60.] 23.Does the patient have a diagnosis of plaque psoriasis? [If no, skip to question 27.] Reference umber: C4416-A / Effective Date: 06/01/2018 4
5 Circle es or o 24.Does the patient have one of the following: a) more than 10% of body surface area involvement with plaque psoriasis, b) less than 10% of BSA affected with involvement of sensitive areas (i.e., hands, feet, face or genitals) that interferes with daily activities, or c) a PASI score of more than 10? [If no, then no further question.] 25.Has the patient tried phototherapy (PUVA, UVB) and has phototherapy been ineffective? If yes, please provide rationale: 26.Has the patient had an inadequate response, intolerance or contraindication to at least one oral systemic therapy such as methotrexate (MTX), cyclosporine for 3 months or more? [If yes, then skip to question 60.] 27.Does the patient have a diagnosis of psoriatic arthritis (PsA)? [If no, skip to question 37.] 28.Does the patient have primarily axial disease or active enthesitis/dactylitis? [If no, skip to question 30.] 29.Did the patient have an inadequate response to a one (1) month trial of TWO non-steroidal anti-inflammatory drugs (SAIDS) at an adequate dose. If yes, please list medications tried: [If no, skip to question 35.] [If yes, skip to question 34.] 30.Does the patient have active psoriatic arthritis? 31.Has the patient had an inadequate response to a three (3) months trial of methotrexate (MTX)? [If yes, skip to question 34.] 32.Did the patient have an intolerance to methotrexate (MTX), sulfasalazine (SSZ), or leflunomide (LEF) for 3 months? [If yes, then skip to question 34.] Reference umber: C4416-A / Effective Date: 06/01/2018 5
6 Circle es or o 33.Does the patient have a contraindication to methotrexate, sulfasalazine (SSZ), or leflunomide (LEF)? ote: Contraindications such as Pregnancy, alcoholism, Chronic liver disease, Leukopenia, thrombocytopenia, or anemia. If yes, please document contraindication: 34.Is the patient currently on or will continue taking SAIDs as needed as bridging or adjunctive therapy with the requested medication? [If yes, then skip to question 60.] 35.Did the patient have an intolerance to TWO oral SAIDs? [If yes, then skip to 60.] 36.Does the patient have contraindications to SAIDs? ote: Contraindications such as true allergic reaction to SAIDs, history of worsening asthma symptoms after taking aspirin or SAIDs, current GI bleed, severe renal dysfunction. If yes, please document contraindication: [If yes, then skip to question 60.] 37.Does the patient have a diagnosis of Crohn s Disease? [If no, skip to question 43.] 38.Has the patient had an inadequate response or intolerable side effects to IV glucocorticoids after 7-10 days or oral prednisone (dosed at 40mg or more per day) for 30 days)? [If yes, skip to question 42.] 39.Does the patient have steroid-dependent Crohn s disease as evidenced by one of the following: A) Patient had a relapse within three months of stopping glucocorticoids; OR B) Patient is unable to taper steroids to an acceptable dose after 3 months without having symptom recurrence? 40. Has the patient had an inadequate response or intolerable side effects with a 3-month trial of azathioprine (AZA), 6-mercaptopurine (6-mp) or injectable Reference umber: C4416-A / Effective Date: 06/01/2018 6
7 methotrexate? Circle es or o [If yes, skip to question 42.] 41.Does the patient have a contraindication to all of the following: azathioprine (AZA), injectable methotrexate and 6-mercaptopurine (6-mp)? If yes, please document contraindication(s): 42.Is the patient at least 18 years old? [If yes, skip to question 61.] 43.Does the patient have a diagnosis of ulcerative colitis (UC)? [If no, skip to question 52.] 44.Has the patient had inadequate response or intolerable side effects to IV glucocorticoids after 7-10 days or oral prednisone (dosed at 40mg or more per day after 30 days)? [If no, skip to question 49.] 45.Has the patient had a previous failure on azathioprine (AZA) AD 6- mercaptopurine (6-MP) OR has a contraindication to azathioprine and 6- mercaptopurine and is therefore not a candidate for treatment with these agents for current episode? If yes, please list medication tried and/or contraindications: 46.Has the patient had surgical intervention for ulcerative colitis (UC)? 47.Has the patient had an inadequate response or intolerable side effects to cyclosporine? 48.Does the patient have a contraindication to cyclosporine? Reference umber: C4416-A / Effective Date: 06/01/2018 7
8 Circle es or o 49.Does the patient have steroid-dependent ulcerative colitis as evidenced by one of the following: A) Patient had a relapse within three months of stopping glucocorticoids; OR B) Patient is unable to taper steroids to an acceptable dose after 3 months without having symptom recurrence? 50.Has the patient had an inadequate response or intolerable side effects with a 3-month trial of azathioprine (AZA) or 6-mercaptopurine (6-MP)? [If yes, skip to question 60.] 51. Does the patient have a contraindication to azathioprine and 6- mercaptopurine? 52.Does the patient have a diagnosis of hidradenitis suppurativa (acne inversa, HS)? [If no, then skip to question 57.] 53.Does the patient have moderate to severe disease (Hurley stage II-III)? ote: Moderate disease: Hurley stage II (recurrent abscesses, with sinus tracts and scarring, presenting as single or multiple widely separated lesions) Severe disease: Hurley state III (diffuse or near-diffuse involvement presenting as multiple interconnected tracts and abscesses across an entire area) 54.Has the patient had an inadequate response or intolerance to an oral antibiotic (e.g., tetracycline, doxycycline or minocycline)? [If yes, then skip to question 60.] 55.Does the patient have contraindication to oral tetracycline? 56.Has the patient had an inadequate response or intolerance to topical antibiotics? [If yes, then skip to question 60.] Reference umber: C4416-A / Effective Date: 06/01/2018 8
9 Circle es or o 57.Does the patient have a diagnosis of uveitis? 58.Has the patient been diagnosed with intermediate, posterior, or pan uveitis that is not caused by an infection? 59.Has the patient had an inadequate response or intolerable side effects with any of the following: corticosteroids, methotrexate, azathioprine, mycophenolate, cyclosporine, tacrolimus; OR not appropriate? 60.Is the patient at least 18 years old? 61.Is Humira being prescribed by, or in consultation with a specialist, based on indication (rheumatologist, dermatologist, gastroenterologist)? 62.Has the patient been screened for latent tuberculosis (TB) and hepatitis B? 63.Does the patient have an active infection (including Hepatitis B and/or tuberculosis (TB)? [If no, skip to question 65.] 64.Is the patient currently receiving or has completed treatment for latent TB infection or Hepatitis B? 65.Will Humira be given in combination with another biologic DMARD? [If yes, then no further questions.] 66.Does the patient have CHF (HA class III or IV)? Comments: Reference umber: C4416-A / Effective Date: 06/01/2018 9
10 Circle es or o I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date Reference umber: C4416-A / Effective Date: 06/01/
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Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Leuprolide (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Multiple Sclerosis Agents (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information2. Did the member receive this medication during a recent hospitalization? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Did the patient receive this medication during a recent hospitalization? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
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More information1. Background: Infliximab is administered parenterally; therefore, it is not covered under retail pharmacy benefits.
Subject: Infliximab (Remicade ) Original Original Committee Approval: October 13, 2006 Revised Last Committee Approval: December 3, 2008 Last Review: October 19, 2007 1. Background: Infliximab is a genetically
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More informationDrugs and Applicable Coding: J-code: Enbrel-J1438; Humira-J0135; Remicade-J1745; Inflectra-Q5102; Cimzia-J0718; Simponi-J1602 Renflexis - pending
Policy Subject: Anti-TNF Agents Policy Number: SHS PBD16 Category: Rheumatology & Autoimmune Policy Type: Medical Pharmacy Department: Pharmacy Product (check all that apply): Group HMO/POS Individual
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More information3. Does the member continue to receive nutritional or psychological counseling?
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 8 Last Review Date: March 17, 2017 Simponi / Simponi
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