3. Has the patient shown improvement in signs and symptoms of the disease? Y N

Transcription

1 Pharmacy Prior Authorization MERC CARE (MEDICAID) Orencia (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 at When conditions are met, we will authorize the coverage of Orencia (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Orencia (abatacept) 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 Orencia in the past for this patient (i.e., previous authorization is on file under this plan)? [If no, skip to question 4.] 2. Is the prescribed dose within the FDA-approved dosing? If requesting IV formulation, please document current weight: 3. Has the patient shown improvement in signs and symptoms of the disease? Reference umber: C4451-A / Effective Date: 06/01/2018 1

2 [o further questions.] Circle es or o 4. Does the patient have a diagnosis of rheumatoid arthritis (RA)? [If no, skip to question 8.] 5. Does the patient have moderate or high disease activity despite an adequate 3-month trial of 2 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), leflunomide (LEF), sulfasalazine (SSZ). Combination regimen: MTX+SSZ+ hydroxychloroquine (HCQ); MTX+HCQ, MTX+LEF, MTX+SSZ, SSZ+HCQ [If yes, skip to question 7.] 6. Does the patient have a contraindication to methotrexate? ote: Contraindications such as pregnancy, alcoholism, chronic liver disease, If yes, please document contraindication: _ 7. Is the patient 18 years of age or older? [If yes, skip to question 28.] 8. Does the patient have a diagnosis of juvenile idiopathic arthritis (JIA)? [If no, skip to question 19.] 9. Does the patient have the systemic subtype of JIA? [If no, skip to question 13.] 10. 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: Reference umber: C4451-A / Effective Date: 06/01/2018 2

3 [If yes, then no further questions.] Circle es or o 11. Does the patient have continued synovitis in at least 1 joint despite treatment for 3 months with methotrexate or leflunomide? 12. Does the patient have contraindications to methotrexate and leflunomide? ote: Contraindications such as pregnancy, alcoholism, chronic liver disease, If yes, please document contraindication: [If no, then no further questions] 13. Does the patient have severe or moderate to severe polyarticular juvenile idiopathic arthritis (pjia)? 14. Has the patient had an inadequate response to a three (3)-month trial of methotrexate? 15. Does the patient have an intolerance or a contraindication to methotrexate? ote: Contraindications such as pregnancy, alcoholism, chronic liver disease, If yes, please document intolerance or contraindication: 16. Has the patient an inadequate response to a three (3)-month trial of sulfasalazine or leflunomide? 17. Is the patient at least 6 years of age? 18. Is the request for the IV formulation of Orencia? [If no, no further questions.] Reference umber: C4451-A / Effective Date: 06/01/2018 3

4 Circle es or o [If yes, skip to question 28.] 19. Does the patient have a diagnosis of psoriatic arthritis (PsA)? 20. Is the patient 18 years of age or older? 21. Does the patient have predominately axial disease or active enthesitis/dactylitis? [If no, skip to question 24.] 22. Has the patient had an inadequate response to a one (1) month trial of TWO non-steroidal anti-inflammatory drugs (SAIDs)? If yes, please list medications tried: [If yes, skip to skip to question 28.] 23. Does the patient have a contraindication or intolerance to TWO oral 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 or intolerance: [If yes, then skip to question 28.] 24. Does the patient have active psoriatic arthritis (PsA)? 25. Has the patient had an inadequate response to a three (3)-month trial of methotrexate? [If yes, skip to question 28.] 26. Does the patient have an intolerance or a contraindication to methotrexate? ote: Contraindications such as pregnancy, alcoholism, chronic liver disease, If yes, please document intolerance or contraindication: Reference umber: C4451-A / Effective Date: 06/01/2018 4

5 Circle es or o 27. Has the patient had an inadequate response to a three (3)-month trial of sulfasalazine or leflunomide? 28. Has the patient had a trial and failure of BOTH Humira and Enbrel? 29.Is Orencia prescribed by or in consultation with a specialist, based on indication (e.g., rheumatologist)? [If no, no further questions.] 30. Has the patient been screened for latent tuberculosis (TB) and hepatitis B? 31. Does the patient have latent tuberculosis (TB) and/or active or chronic Hepatitis B infection? [If no, skip to question 33.] 32. Is the patient currently receiving or has completed treatment for latent TB infection or Hepatitis B? 33. Has the patient been evaluated for and given the appropriate vaccinations as recommended per the Centers for Disease Control and Prevention (CDC) for his/her risk factors? 34. Will Orencia be given in combination with another cytokine or cell adhesion molecule (CAM) antagonist? [If yes, no further questions.] 35. Is the prescribed dose within the FDA-approved dosing? If requesting IV formulation, please document current weight: Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Date Prescriber (Or Authorized) Signature Date Reference umber: C4451-A / Effective Date: 06/01/2018 5