2. Has the patient had a response to treatment? Y N. 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? Y N
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1 12/21/2016 Prior Authorization Aetna Better Health of West Virginia Humira (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health of West Virginia at When conditions are met, we will authorize the coverage of Humira (WV88). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (select from list of drugs shown) Humira (adalimumab) Quantity Frequency Strength Route of Administration Expected Length of therapy Patient Information Patient ame: Patient ID: Patient Group o.: Patient DOB: Patient Phone: Prescribing Physician Physician ame: Specialty: PI umber: Physician Fax: Physician Phone: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. Question 1. Has Aetna Better Health of West Virginia authorized this medication in the past for this patient (i.e., previous authorization is on file with Aetna Better Health of West Virginia)? [If no, skip to question 3.] 2. Has the patient had a response to treatment? [o further questions.] 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? [If yes, skip to question 7.] 4. Does the patient have a diagnosis of psoriatic arthritis? [If no, skip to question 8.]
2 5. Has the patient had a documented 90 day trial of SAID therapy? List SAIDs tried or submit records: [If yes, skip to question 7.] 6. Does the patient have any of the following contraindications to SAIDs? A) True allergic reaction to SAIDs; B) History of worsening asthma symptoms after taking aspirin or SAIDs; C) Current GI bleed; or D) Severe renal dysfunction If yes, please indicate which contraindication(s): 7. Has the patient had documented 90 day trials of at least two DMARDs (disease-modifying antirheumatic drugs, e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine)? 8. Does the patient have a diagnosis of ankylosing spondylitis (AS)? [If no, skip to question 11.] 9. Has the patient had a documented 90 day trial of SAID therapy? List SAIDs tried or submit records: 10. Does the patient have any of the following contraindications to SAID s? A) True allergic reaction to SAID s; B) History of worsening asthma symptoms after taking aspirin or SAIDs; C) Current GI bleed; or D) Severe renal dysfunction If yes, please indicate which contraindication(s):
3 11. Does the patient have a diagnosis of juvenile idiopathic arthritis? [If no, skip to question 14.] 12. Has the patient tried and failed a 90 day course of therapy with methotrexate? 13. Is the patient at least 2 years of age? [If yes, skip to question 32.] 14. Does the patient have a diagnosis of moderate to severe psoriasis? [If no, skip to question 18.] 15. Has the patient had prior treatment with a potent topical corticosteroid plus calcipotriol or calcipotriene? 16. Has the patient had prior treatment with phototherapy? 17. Has the patient had a prior 90 day trial with a disease-modifying agent (DMARD) such as methotrexate, cyclosporine, acitretin, etc? 18. Does the patient have a diagnosis of moderate to severe Crohn s disease? [If no, skip to question 22.] 19. Is the request for a pediatric patient? [If no, skip to question 31.] 20. Is the patient at least 6 years of age?
4 21. Has the patient had a documented inadequate response to a 14- day trial of corticosteroids or an immunomodulator such as azathioprine, 6-mercaptopurine, or methotrexate? [If yes, skip to question 32.] 22. Does the patient have a diagnosis of ulcerative colitis (UC)? [If no, skip to question 25.] 23. Has the patient required treatment with corticosteroids such as prednisone for two or more colitis flares while taking an aminosalicylate (e.g. sulfasalazine, mesalamine) for a minimum of 30 days? 24. Did the patient have clinically significant adverse effects to aminosalicylates (e.g. sulfasalazine, mesalamine)? If yes, please indicate adverse effect(s) if applicable: 25. Does the patient have a diagnosis of hidradenitis suppurative (acne inversa, HS)? [If no, skip to question 29.] 26. Does the patient have at least 3 abscesses or inflammatory nodules? 27. Does the patient have severe disease (Hurley stage III)?
5 28. Does the patient have moderate disease (Hurley stage II) despite treatment with an oral tetracycline (i.e., doxycycline) or topical clindamycin? 29. Does the patient have a diagnosis of non-infectious Uveitis? 30. Has the patient had an inadequate response to corticosteroid therapy or corticosteroid therapy is not appropriate? 31. Is the patient at least 18 years of age? 32. Has the patient had a negative tuberculin skin test before initiation of therapy? 33. Was an initial treatment plan done in consultation with an appropriate specialist (such as a dermatologist, gastroenterologist or rheumatologist)? List specialty: Comments: 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
Pharmacy Prior Authorization
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationCircle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.
06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information3. Did the patient show evidence of remission by week 8 of Humira Y N therapy?
09/23/2015 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
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More information2. Does the patient have a diagnosis of ulcerative colitis or Crohn s? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH LOUISIAA (MEDICAID) Remicade (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information3. Has the patient shown improvement in signs and symptoms of the disease? Y N
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More information2. Does the patient have a diagnosis of Crohn s disease? Y N
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Stelara (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More information3. Does the patient have a diagnosis of rheumatoid arthritis (RA) with moderate to high disease activity?
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Enbrel (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
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Humira (adalimumab) Medication Request Form (MRF) for Healthy Indiana Plan (HIP) and Hoosier Healthwise (HHW) FAX TO: (858) 790-7100 c/o MedImpact Healthcare Systems, Inc. Attn: Prior Authorization Department
More information1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.
LENGTH OF AUTHORIZATION: Initial: 3 months for Crohn s or Ulcerative Colitis; 1 year for all other indications. Renewal: 1 year dependent upon medical records supporting response to therapy and review
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Prescriber Information Last ame: First ame DEA/PI: Specialty: Phone - - Fax - - Member Information Last ame: First ame Member ID umber DOB: - - Medication Information: Drug ame and Strength: Diagnosis:
More information2. Does the patient have a diagnosis of giant cell arteritis (GCA)? Y N
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More information3. Does the patient continue to receive nutritional or psychological counseling? Y N
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More information[If no, skip to question 10.] Y N. 2. Does the member have a diagnosis of Paget s disease of bone? Y N. [If no, skip to question 4.
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Zoledronic Acid (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information2. Does the patient have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)?
Pharmacy Prior Authorization MERC CARE (MEDICAID) Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
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