3. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing for giant cell arteritis?

Transcription

1 Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Actemra (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 Pennsylvania / Aetna Better Health Kids at When conditions are met, we will authorize the coverage of Actemra (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Actemra (tocilizumab) 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. 1. Has this plan authorized Actemra in the past for this member (i.e., previous authorization is on file under this plan)? [If no, skip to question 6.] 2. Does the member have a diagnosis of giant cell arteritis (GCA)? [If no, skip to question 4.] 3. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing for giant cell arteritis? Reference umber: C14619-A / Effective Date: 12/20/2018 1

2 [If yes, skip to question 5.] 4. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing (based on weight)? Please document current weight: 5. Has the member shown improvement in signs and symptoms of the disease? [o further questions.] 6. Does the member have a diagnosis of active moderate to severe rheumatoid arthritis (RA) (e.g., swollen, tender joints with limited range of motion)? [If no, skip to question 13.] 7. Has the member had an inadequate response to a three (3)-month trial of two different non-biologic disease modifying anti-rheumatic drug (DMARD) regimens (one of which must include methotrexate)? If yes, list medications tried: ote: Monotherapy regimen: methotrexate (MTX), hydroxychloroquine (HCQ), leflunomide (LEF), sulfasalazine (SSZ). Combination regimen: MTX+SSZ+HCQ; MTX+HCQ, MTX+LEF, MTX+SSZ, SSZ+HCQ [If yes, skip to question 10.] 8. Does the member have an intolerance or a contraindication to methotrexate? ote: Contraindications such as pregnancy, alcoholism, chronic liver disease, leukopenia, thrombocytopenia, or anemia. If yes, please document intolerance or contraindication: 9. Has the member had an inadequate response to a three (3)-month trial of sulfasalazine or leflunomide? 10. Has the member had a trial and failure of at least one formulary anti-tumor necrosis factor (TF)? Reference umber: C14619-A / Effective Date: 12/20/2018 2

3 Please list agent tried: [If yes, skip to question 12.] 11. Is the member new or returning to the plan and is already using Actemra? 12. Is the member at least 18 years of age? [If yes, skip to question 35.] 13. Does the member have a diagnosis of juvenile idiopathic arthritis (JIA)? [If no, skip to question 27.] 14. Does the member have the systemic subtype of juvenile idiopathic arthritis (JIA)? [If no, skip to question 19.] 15. Does the member currently have ACTIVE systemic features? ote: Systemic features such as fever, evanescent rash, lymphadenopathy, hepatomegaly, splenomegaly, or serositis. If yes, please list: [If yes, skip to question 17.] 16. Does the member have continued synovitis in at least 1 joint despite treatment for 3 months with methotrexate or leflunomide? [If yes, skip to question 25.] 17. Does the member have a physician s global assessment of overall disease activity (MD global) greater than or equal to 5? ote: o joints with synovitis required. [If yes, skip to question 25.] 18. Does the member have a physician s global assessment of overall disease activity (MD global) less than 5 and at least 1 joint with synovitis? [If yes, skip to question 25.] 19. Does the member have polyarticular juvenile idiopathic arthritis (JIA)? Reference umber: C14619-A / Effective Date: 12/20/2018 3

4 20. Has the member an inadequate response to a three (3)-month trial of methotrexate? [If yes, skip to question 23.] 21. Does the member have an intolerance or a contraindication to methotrexate? ote: Contraindications such as pregnancy, alcoholism, chronic liver disease, leukopenia, thrombocytopenia, or anemia. If yes, please document intolerance or contraindication: 22. Has the member an inadequate response to a three (3)-month trial of sulfasalazine or leflunomide? 23. Has the member had a trial and failure of at least one formulary anti-tumor necrosis factor (TF)? Please list agent tried: [If yes, skip to question 25.] 24. Is the member new or returning to the plan and is already using Actemra? 25. Is the member at least 2 years of age? 26. Is the request for the IV formulation? OTE: SQ use is not FDA-approved for juvenile idiopathic arthritis (JIA). [If yes, skip to question 35.] 27. Does the member have a diagnosis of giant cell arteritis (GCA)? 28. Has the member had an inadequate response with glucocorticoids (e.g., prednisone, methylprednisolone)? Please list agent tried: [If no, skip to question 30.] Reference umber: C14619-A / Effective Date: 12/20/2018 4

5 29. Will Actemra be used in combination with a tapering course of glucocorticoids? [If yes, skip to question 32.] 30. Does the member have an intolerance or a contraindication with glucocorticoids (e.g., prednisone, methylprednisolone)? If yes, please document intolerance or contraindication: 31. Has the member tried methotrexate or cyclophosphamide? 32. Is the member at least 18 years of age? 33. Is the request for the SQ formulation? OTE: IV use is not FDA-approved for giant cell arteritis (GCA). 34. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing for giant cell arteritis? [If yes, skip to question 36.] 35. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing (based on weight)? Please document current weight or submit records: OTE: requests without member s weight will not be accepted. 36. Is Actemra being prescribed by, or in consultation with a specialist, based on indication (e.g., rheumatologist)? 37. Has the member been screened for tuberculosis (TB)? 38. Does the member have latent tuberculosis (TB) infection? Reference umber: C14619-A / Effective Date: 12/20/2018 5

6 [If no, skip to question 40.] 39. Is the member currently receiving or has completed treatment for latent tuberculosis (TB) infection? 40. Has the member been screened for hepatitis B? 41. Does the member have active or chronic hepatitis B infection? [If no, skip to question 43.] 42. Is the member currently receiving or has completed treatment for hepatitis B? 43. Has the member been evaluated for and given the appropriate vaccinations as recommended per the Centers for Disease Control and Prevention (CDC) for his/her risk factors? 44. Will Actemra be given in combination with another cytokine or cell adhesion molecule (CAM) antagonist? 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: C14619-A / Effective Date: 12/20/2018 6