Pharmacy Prior Authorization

Transcription

1 Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Enbrel (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 Aetna Better Health Kentucky at When conditions are met, we will authorize the coverage of Enbrel (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Enbrel (etanercept) 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 Enbrel 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: C4413-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 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: C4413-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 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.Did 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. 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: C4413-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 If yes, please document contraindication: 18.Is the patient at least 2 years of age? [If yes, skip to question 39.] 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 21.] 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, then skip to question 38.] 23.Does the patient have a diagnosis of plaque psoriasis? Reference umber: C4413-A / Effective Date: 06/01/2018 4

5 [If no, skip to question 27.] 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 37.] 27.Does the patient have a diagnosis of psoriatic arthritis (PsA)? 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 yes, skip to question 34.] [If no, skip to question 35.] 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.] Reference umber: C4413-A / Effective Date: 06/01/2018 5

6 Circle es or o 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.] 33.Does the patient have a contraindication to methotrexate, sulfasalazine (SSZ), or leflunomide (LEF)? ote: Contraindications such as Pregnancy, alcoholism, Chronic liver 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 38.] 35.Did the patient have an intolerance to TWO oral SAIDs? 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. 37.Is the patient at least 4 years old? [If yes, skip to question 39.] 38.Is the patient at least 18 years of age? 39.Is Enbrel being prescribed by, or in consultation with a specialist, based on indication (rheumatologist or dermatologist)? List specialty: Reference umber: C4413-A / Effective Date: 06/01/2018 6

7 Circle es or o 40.Has the patient been screened for latent tuberculosis (TB) and hepatitis B? 41.Does the patient have an active infection (including Hepatitis B and/or tuberculosis (TB)? [If no, skip to question 43.] 42.Is the patient currently receiving or has completed treatment for latent TB infection or Hepatitis B? 43.Will Enbrel be given in combination with another biologic DMARD? [If yes, then no further questions.] 44.Does the patient have CHF (HA class III or IV)? 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 Reference umber: C4413-A / Effective Date: 06/01/2018 7