3. Did the patient show evidence of remission by week 8 of Humira Y N therapy?

Size: px
Start display at page:

Download "3. Did the patient show evidence of remission by week 8 of Humira Y N therapy?"

Transcription

1 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, sign and date. Fax signed forms to Aetna Better Health of Michigan at Please contact Aetna Better Health of Michigan at with questions regarding the Prior Authorization process. When conditions are met, we will authorize the coverage of Humira (MI88). 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) Other, Please specify: 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 Circle es or o 1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)? [If no, skip to question 5.] 2. Does the patient have a diagnosis of ulcerative colitis? [If no, skip to question 4.] 3. Did the patient show evidence of remission by week 8 of Humira therapy? [o further questions.]

2 Circle es or o 4. Is the patient responding to Humira therapy? [o further questions.] 5. Initial Authorization: Rheumatoid Arthritis (RA) Does the patient have a diagnosis of moderate to severe rheumatoid arthritis? [If no, skip to question 8.] 6. Is the patient at least 18 years of age? 7. Does the patient meet OE of the following? Please indicate which of methotrexate and other DMARDs, list drugs and contraindications/intolerance): Trial and failure of methotrexate and at least 1 other oral DMARD (sulfasalazine, hydroxychloroquine or leflunomide) as sequential monotherapy for 3 months each or in combination for at least 3 months OR \ Patient has contraindication/intolerance to methotrexate and other DMARDs 8. Initial Authorization: Juvenile Idiopathic Arthritis (JIA) Does the patient have a diagnosis of juvenile idiopathic arthritis? [If no, skip to question 11.] 9. Is the patient at least 4 years of age? 10. Does the patient meet OE of the following? Please indicate which of methotrexate, list contraindication/intolerance): Trial and failure of at least 3 consecutive months of methotrexate \ Patient has contraindication/intolerance to use of methotrexate 11. Initial Authorization: Anklylosing Spondylitis (AS) Does the patient have a diagnosis of ankylosing spondylitis? [If no, skip to question 14.]

3 12.Is the patient at least 18 years of age? Circle es or o 13.Does the patient meet OE of the following? Please indicate which of SAIDs, list contraindication): Trial and failure of two different SAIDs (e.g., ibuprofen, naproxen, etodolac, meloxicam, indomethacin) within the last 60 days OR \ Patient has contraindication to SAIDs 14.Initial Authorization: Plaque Psoriasis Does the patient have a diagnosis of chronic moderate to severe plaque psoriasis? [If no, skip to question 17.] 15.Does the patient meet OE of the following? Please indicate which of UVB and PUVA, list contraindication): Trial and failure of phototherapy (UVB or PUVA),OR \ Patient has contraindication to UVB and PUVA 16.Does the patient meet OE of the following? Please indicate which of methotrexate, list contraindication): Trial and failure of methotrexate for at least 3 months \ Patient has contraindication/intolerance to use of methotrexate 17.Initial Authorization: Psoriatic Arthritis Does the patient meet all of the following? Diagnosis is moderate to severe psoriatic arthritis \ Patient is at least 18 years old [If no, skip to question 19.]

4 18. Does the patient meet OE of the following? Please indicate which of methotrexate, list contraindication): Circle es or o Trial and failure of a compliant regimen of methotrexate for at least 3 months \ Patient has contraindication to use of methotrexate 19. Initial Authorization: Chrohn's Disease Does the patient meet ALL of the following? Diagnosis is moderate to severe active Crohn s disease \ Patient is at least 6 years old [If no, skip to question 24.] 20. Has the patient experienced treatment failure or intolerance to Remicade? [If yes, no further questions] 21. Does the patient meet OE of the following? Please indicate which of corticosteroids, list contraindication): Trial and failure of oral or intravenous corticosteroids for at least one month OR \ Patient has contraindication to corticosteroids. 22. Does the patient meet OE of the following? Please indicate which of azathioprine and mercaptopurine, list contraindication): Trial and failure of a 3-month compliant regimen of azathioprine or mercaptopurine OR \ Patient has contraindication to azathioprine and mercaptopurine. 23. Does the patient meet OE of the following? Please indicate which of methotrexate, list contraindication):

5 Trial and failure of a 3-month compliant regimen of parenteral methotrexate OR \ Patient has contraindication to parenteral methotrexate. Circle es or o 24.Initial Authorization: Ulcerative Colitis Does the patient meet ALL of the following? Diagnosis is moderate to severe ulcerative colitis \ Patient is at least 18 years old [If no, no further questions] 25.Does the patient meet OE of the following? Please indicate which of aminosalicylates, list contraindication/intolerance): Trial and failure of a compliant regimen of oral or rectal aminosalicylates (e.g., mesalamine, sulfasalazine) for 2 consecutive months OR \ Patient has contraindication/intolerance to aminosalicylates. 26.Does the patient meet OE of the following? Please indicate which of corticosteroids, list contraindication): Trial and failure of oral or intravenous corticosteroids for at least one month OR \ Patient has contraindication to corticosteroids 27.Does the patient meet OE of the following? Please indicate which of azathioprine and mercaptopurine, list contraindication/intolerance): Trial and failure of a 3-month compliant regimen of azathioprine or mercaptopurine OR \ Patient has contraindication/intolerance to azathioprine and mercaptopurine.

6 Circle es or o 28.Is Humira being prescribed by, or in consultation with a specialist, based on indication (rheumatologist, dermatologist, gastroenterologist)? 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

2. Is the patient responding to Remicade therapy? Y N

2. Is the patient responding to Remicade therapy? Y N 09/29/2015 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Remicade (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

Circle 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.

Circle 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 information

2. Has the patient had a response to treatment? Y N. 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? Y N

2. Has the patient had a response to treatment? Y N. 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? Y N 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

More information

2. Does the patient have a diagnosis of ulcerative colitis or Crohn s? Y N

2. 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 information

2. Does the patient have a diagnosis of Crohn s disease? Y N

2. 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 information

Pharmacy Prior Authorization

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 information

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

3. Has the patient shown improvement in signs and symptoms of the disease? Y N Pharmacy Prior Authorization MERC CARE (MEDICAID) Renflexis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization 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

More information

3. Does the patient have a diagnosis of rheumatoid arthritis (RA) with moderate to high disease activity?

3. 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

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization 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

More information

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

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

More information

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

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

More information

2. Does the patient have a diagnosis of giant cell arteritis (GCA)? Y N

2. Does the patient have a diagnosis of giant cell arteritis (GCA)? Y N Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Actemra (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

2. Is the patient responding to medication? Y N

2. Is the patient responding to medication? Y N Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS ADD-ADHD Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

Drug Name (specify drug) Quantity Frequency Strength

Drug Name (specify drug) Quantity Frequency Strength Prior Authorization Form GEHA FEDERAL - STANDARD OPTION Autoimmune Conditions (FA-PA) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES HUMIRA PEDIATRIC

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES HUMIRA PEDIATRIC Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA 24800 HUMIRA PEDIATRIC GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the patient currently taking Humira? If

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.

1 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

More information

First Name. Specialty: Fax. First Name DOB: Duration:

First Name. Specialty: Fax. First Name DOB: Duration: 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 information

Circle Yes or No Y N. [If no, skip to question 8.] 2. Has the patient been compliant with therapy as verified by the prescriber?

Circle Yes or No Y N. [If no, skip to question 8.] 2. Has the patient been compliant with therapy as verified by the prescriber? 06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Tecfidera (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

1. Does the patient have a diagnosis of moderate to severe polyarticular juvenile idiopathic arthritis (PJIA)?

1. Does the patient have a diagnosis of moderate to severe polyarticular juvenile idiopathic arthritis (PJIA)? 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 information

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES Generic Brand HICL GCN Exception/Other CERTOLIZUMAB PEGOL CIMZIA 35554 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the request for a patient with a diagnosis of moderate

More information

2. Does the patient have chronic urticaria? Y N

2. Does the patient have chronic urticaria? Y N Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Xolair (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization 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

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.

[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 information

3. Has bone specific alkaline phosphatase level increased OR does the member have symptoms related to active Paget s?

3. Has bone specific alkaline phosphatase level increased OR does the member have symptoms related to active Paget s? Pharmacy Prior Authorization AETA BETTER HEALTH VIRGIIA CCC PLUS and MEDALLIO/FAMIS 4.0 Zoledronic Acid (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

2. Does the patient have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)?

2. 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

More information

3. Does the patient meet ALL of the following requirements? Y N

3. Does the patient meet ALL of the following requirements? Y N Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA Procrit - Retacrit (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES Generic Brand HICL GCN Exception/Other GOLIMUMAB SIMPONI 22533, 22536, 34697, 35001 ROUTE = SUBCUTANE. GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the request for a

More information

2. Does the member have a diagnosis of central precocious puberty? Y N

2. Does the member have a diagnosis of central precocious puberty? Y N 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 information

Priority Health Medicare prior authorization form Fax completed form to: toll free, or

Priority Health Medicare prior authorization form Fax completed form to: toll free, or Priority Health Medicare prior authorization form Fax completed form to: 877.974.4411 toll free, or 616.942.8206 This form applies to: Medicare Part B Medicare Part D This request is: Expedited request

More information

3. Have baseline A1c or fasting glucose, thyroid-stimulating hormone (TSH), and electrocardiography (EKG) been checked?

3. Have baseline A1c or fasting glucose, thyroid-stimulating hormone (TSH), and electrocardiography (EKG) been checked? Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Somatostatin Analogs (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization Pharmacy Prior Authorization AETA BETTER HEALTH ILLIOIS (MEDICAID) CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

2. Is this request for a preferred medication? Y N

2. Is this request for a preferred medication? Y N Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

3. Has the member received the requested drug for less than 2 years? Y N

3. Has the member received the requested drug for less than 2 years? Y N Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Zoladex (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)?

1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)? 09/07/2016 Prior Authorization AETA BETTER HEALTH OF KETUCK (MEDICAID) PCSK9 Inhibitors (K88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

3. Has the member received the requested drug for less than 2 years? Y N

3. Has the member received the requested drug for less than 2 years? Y N Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Zoladex (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

ADALIMUMAB Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)

ADALIMUMAB Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA 24800 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Does the patient have a diagnosis of moderate to severe rheumatoid

More information

3. Has the patient had a sustained improvement in Pain or Function (e.g. PEG scale with a 30 percent response from baseline)?

3. Has the patient had a sustained improvement in Pain or Function (e.g. PEG scale with a 30 percent response from baseline)? Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

3. Does the patient continue to receive nutritional or psychological counseling? Y N

3. Does the patient continue to receive nutritional or psychological counseling? Y N 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

More information

SAMPLE IgE: ESR: CRP: # Joints: %BSA: Height: Weight: BMI:

SAMPLE IgE: ESR: CRP: # Joints: %BSA: Height: Weight: BMI: Please Note: Medical Necessity Prior Authorization may be overrided for both formulary coverage and benefit design restrictions. They are issued at the full discretion of the benefit manager. PRIOR AUTHORIZATION

More information

2. Did the patient receive this medication during a recent hospitalization? Y N

2. 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

More information

2. Did the member receive this medication during a recent hospitalization? Y N

2. 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 information

Circle Yes or No Y N. (Note: requests without this information will not be accepted.) [If no, then no further questions.]

Circle Yes or No Y N. (Note: requests without this information will not be accepted.) [If no, then no further questions.] 04/25/2016 Prior Authorization AETA BETTER HEALTH OF LA MEDICAID Colony Stimulating Factors (LA88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist?

2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist? Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Colony Stimulating Factors (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

Prior Authorization Conditions for Approval of Humira (adalimumab) Website Form Submit request via: Fax

Prior Authorization Conditions for Approval of Humira (adalimumab) Website Form  Submit request via: Fax Prior Authorization Conditions for Approval of Humira (adalimumab) Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for Humira (adalimumab) require a prior

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Anticoagulant Injectable (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization Pharmacy Prior Authorization AETA BETTER HEALTH VIRGIIA Multiple Sclerosis Agents (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

3. Does the member continue to receive nutritional or psychological counseling?

3. 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

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization Pharmacy Prior Authorization MERC CARE (MEDICAID) Colony Stimulating Factors (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

Circle Yes or No Y N. [If yes, skip to question 13 REAUTHORIZATION REQUESTS]

Circle Yes or No Y N. [If yes, skip to question 13 REAUTHORIZATION REQUESTS] 04/30/2014 Prior Authorization AETA BETTER HEALTH OF ILLIOIS MEDICAID Peginterferon (IL88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

Subject: Remicade (Page 1 of 5)

Subject: Remicade (Page 1 of 5) Subject: Remicade (Page 1 of 5) Objective: I. To ensure that Health Share/Tuality Health Alliance (THA) has a process by which the appropriate utilization of Remicade (Infliximab) for members whose diagnosis

More information

C. Assess clinical response after the first three months of treatment.

C. Assess clinical response after the first three months of treatment. Government Health Plan (GHP) of Puerto Rico Authorization Criteria Tumor Necrosis Factor Alpha (TNFα) Adalimumab (Humira ) Managed by MCO Section I. Prior Authorization Criteria A. Physician must submit

More information

Prior Authorization Conditions for Approval of Enbrel (etanercept) Website Form Submit request via: Fax

Prior Authorization Conditions for Approval of Enbrel (etanercept) Website Form   Submit request via: Fax Prior Authorization Conditions for Approval of Enbrel (etanercept) Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for Enbrel (etanercept) require a prior

More information

Circle Yes or Y N. [Note: requests without this information will not be accepted.] [If no, then no further questions.

Circle Yes or Y N. [Note: requests without this information will not be accepted.] [If no, then no further questions. 10/01/2016 Prior Authorization Aetna Better Health of West Virginia COLO STIMULATIG FACTORS (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

Prior Authorization. Drug Name (select from list of drugs shown) Gilenya (fingolomid) Quantity Frequency Strength. Physician Name:

Prior Authorization. Drug Name (select from list of drugs shown) Gilenya (fingolomid) Quantity Frequency Strength. Physician Name: 06/01/2016 Prior Authorization Aetna Better Health Michigan Gilenya This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed

More information

Circle Yes or No Y N. [If yes, skip to question 29.] 2. Is the request for Sandostatin LAR? Y N. [If no, skip to question 5.] Prior Authorization

Circle Yes or No Y N. [If yes, skip to question 29.] 2. Is the request for Sandostatin LAR? Y N. [If no, skip to question 5.] Prior Authorization 04/03/2016 Prior Authorization MERC MARICOPA ITEGRATED CARE - TXIX/XXI SMI (MEDICAID) Somatostatin Analogs and Somavert (AZ88) This fax machine is located in a secure location as required by HIPAA regulations.

More information

Circle Yes or No Y N. [If yes, skip to question 30.] 2. Is this request for a child? Y N. [If no, skip to question 20.]

Circle Yes or No Y N. [If yes, skip to question 30.] 2. Is this request for a child? Y N. [If no, skip to question 20.] 05/20/2015 Prior Authorization MERC CARE PLA (MEDICAID) Growth Hormone (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and

More information

ETANERCEPT Generic Brand HICL GCN Exception/Other ETANERCEPT ENBREL GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)

ETANERCEPT Generic Brand HICL GCN Exception/Other ETANERCEPT ENBREL GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) Generic Brand HICL GCN Exception/Other ETANERCEPT ENBREL 18830 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Does the patient have a diagnosis of moderate to severe rheumatoid

More information

Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases

Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases Line of Business: Medicaid P & T Approval Date: August 16, 2017 Effective Date: August 16, 2017 This policy

More information

Prior Authorization. Drug Name (select from list of drugs shown) Viekira Pak (ombitasv-paritaprev-ritonav-dasabuv) Quantity Frequency Strength

Prior Authorization. Drug Name (select from list of drugs shown) Viekira Pak (ombitasv-paritaprev-ritonav-dasabuv) Quantity Frequency Strength 06/01/2016 Prior Authorization Aetna Better Health Texas Viekara Pak w or w/o Ribavirin First Fill (Med) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

Please submit supporting medical documentation, notes and test results.

Please submit supporting medical documentation, notes and test results. Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA Valcyte (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date.

More information

[If yes, no further questions.]

[If yes, no further questions.] 05/30/2014 Prior Authorization AETA BETTER HEALTH OF ILLIOIS MEDICAID Botox (IL88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and

More information

UnitedHealthcare Pharmacy Clinical Pharmacy Programs

UnitedHealthcare Pharmacy Clinical Pharmacy Programs UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2017 P 1041-8 Program Prior Authorization/Notification Medication Humira (adalimumab) P&T Approval Date 1/2007, 6/2008, 4/2009, 6/2009,

More information

Request for Special Authorization Enbrel

Request for Special Authorization Enbrel Certain prescription drugs call for a more detailed assessment to help ensure that they represent reasonable treatment. Special Authorization requires that you request approval from Great-West Life for

More information

1. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

1. 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 EW JERSE (MEDICAID) Eligard Trelstar - Vantas (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

2. 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 MICHIGA Botulinum Toxins (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

2. 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 information

Circle Yes or No Y N. [If yes, no further questions.]

Circle Yes or No Y N. [If yes, no further questions.] 02/18/2016 Prior Authorization AETA BETTER HEALTH PE MEDICAID & AETA BETTER HEALTH KIDS Botulinum Toxins (PA88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

Circle Yes or No Y N. [If no, then no further questions.]

Circle Yes or No Y N. [If no, then no further questions.] 01/04/2016 Prior Authorization MERC MARICOPA ITEGRATED CARE - TXIX/XXI SMI (MEDICAID) Multiple Sclerosis Agents (AZ88) This fax machine is located in a secure location as required by HIPAA regulations.

More information

INFLIXIMAB Remicade (infliximab), Inflectra (infliximab-dyyb), Ixifi* (infliximabqbtx), Renflexis (infliximab-abda)

INFLIXIMAB Remicade (infliximab), Inflectra (infliximab-dyyb), Ixifi* (infliximabqbtx), Renflexis (infliximab-abda) Pre - PA Allowance None Prior-Approval Requirements Diagnoses Patient must have ONE of the following: 6 years of age or older 1. Moderate to severe Crohn s disease (CD) a. Patient has fistulizing disease

More information

Inflectra Frequently Asked Questions

Inflectra Frequently Asked Questions Inflectra Frequently Asked Questions 1. What is the funding status of Inflectra (infliximab)? Earlier in 2016, Inflectra (infliximab) was added to the Ontario Drug Benefit (ODB) Formulary as a Limited

More information

2. Is the request for Humatrope? Y N [If no, skip to question 6.]

2. Is the request for Humatrope? Y N [If no, skip to question 6.] Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA Growth Hormone Agents This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date.

More information

Remicade (infliximab) DRUG.00002

Remicade (infliximab) DRUG.00002 Applicability/Effective Date *- Florida Healthy Kids Remicade (infliximab) DRUG.00002 Override(s) Prior Authorization Step Therapy Medications Remicade (infliximab) Approval Duration 1 year Comment Intravenous

More information

1. Background: Infliximab is administered parenterally; therefore, it is not covered under retail pharmacy benefits.

1. 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

More information

Pharmacy Management Drug Policy

Pharmacy Management Drug Policy SUBJECT: Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs POLICY NUMBER: PHARMACY-73 EFFECTIVE DATE: 01/01/2018 LAST REVIEW DATE: 06/11/2018 If the member s subscriber

More information

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

2. 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 EW JERSE (MEDICAID) Multiple Sclerosis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

2. 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 MERC CARE (MEDICAID) Multiple Sclerosis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: Infliximab (Remicade), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis) Reference Number: ERX.SPA.160 Effective Date: 10.01.16 Last Review Date: 05.18 Revision Log See Important

More information

Immune Modulating Drugs Prior Authorization Request Form

Immune Modulating Drugs Prior Authorization Request Form Patient: HPHC member ID #: Requesting provider: Phone: Servicing provider: Diagnosis: Contact for questions (name and phone #): Projected start and end date for requested Requesting provider NPI: Fax:

More information

Clinical Policy: Certolizumab (Cimzia) Reference Number: ERX.SPA.167 Effective Date:

Clinical Policy: Certolizumab (Cimzia) Reference Number: ERX.SPA.167 Effective Date: Clinical Policy: (Cimzia) Reference Number: ERX.SPA.167 Effective Date: 10.01.16 Last Review Date: 11.17 Revision Log See Important Reminder at the end of this policy for important regulatory and legal

More information

Clinical Policy: Certolizumab (Cimzia) Reference Number: ERX.SPA.167 Effective Date:

Clinical Policy: Certolizumab (Cimzia) Reference Number: ERX.SPA.167 Effective Date: Clinical Policy: (Cimzia) Reference Number: ERX.SPA.167 Effective Date: 1.1.16 Last Review Date: 11.17 Revision Log See Important Reminder at the end of this policy for important regulatory and legal information.

More information

Inflectra (infliximab-dyyb), Remicade (infliximab), Renflexis (infliximab-abda) DRUG CG-DRUG-64

Inflectra (infliximab-dyyb), Remicade (infliximab), Renflexis (infliximab-abda) DRUG CG-DRUG-64 Inflectra (infliximab-dyyb), Remicade (infliximab), Renflexis (infliximab-abda) DRUG.00002 CG-DRUG-64 Override(s) Prior Authorization *Washington Medicaid See State Specific Mandates Medications Inflectra

More information

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

2. 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 Growth Hormone (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and

More information

2. Is the request for Alli, Xenical or Belviq? Y N. 3. Has the patient received 6 months or more of therapy? Y N

2. Is the request for Alli, Xenical or Belviq? Y N. 3. Has the patient received 6 months or more of therapy? Y N Prior Authorization MERC CARE PLA Weight Reduction Medications (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date.

More information

Infliximab/Infliximab-dyyb DRUG.00002

Infliximab/Infliximab-dyyb DRUG.00002 Infliximab/Infliximab-dyyb DRUG.00002 Override(s) Prior Authorization Step Therapy Medications Remicade (infliximab) Inflectra (inflectra-dyyb) Approval Duration 1 year Comment Intravenous administration

More information

Clinical Policy: Certolizumab (Cimzia) Reference Number: PA.CP.PHAR.247 Effective Date: 01/18 Last Review Date: 08/17 Line of Business: Medicaid

Clinical Policy: Certolizumab (Cimzia) Reference Number: PA.CP.PHAR.247 Effective Date: 01/18 Last Review Date: 08/17 Line of Business: Medicaid Clinical Policy: (Cimzia) Reference Number: PA.CP.PHAR.247 Effective Date: 01/18 Last Review Date: 08/17 Line of Business: Medicaid Coding Implications Revision Log Description (Cimzia ) is a tumor necrosis

More information

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

2. 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 MERC CARE PLA (MEDICAID) Botulinum Toxins (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and

More information

Drug Name (specify drug) Quantity Frequency Strength

Drug Name (specify drug) Quantity Frequency Strength Prior Authorization Form GEHA FEDERAL - STANDARD OPTION 1363-M Opioids IR MME Limit and Post Limit This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: Infliximab (Remicade, Inflectra, Renflexis) Reference Number: CP.PHAR.254 Effective Date: 07.16 Last Review Date: 05.18 Line of Business: Medicaid Coding Implications Revision Log See

More information

Biologics for Autoimmune Diseases

Biologics for Autoimmune Diseases Biologics for Autoimmune Diseases Goal(s): Restrict use of biologics to OHP funded conditions and according to OHP guidelines for use. Promote use that is consistent with national clinical practice guidelines

More information

Drug Name (specify drug) Quantity Frequency Strength

Drug Name (specify drug) Quantity Frequency Strength Prior Authorization Form MEDICA HEALTH PLAN IA EXCHANGE 1362-M Opioids IR Labeling Post Limit (HMF) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

Ontario Public Drug Programs. Inflectra (infliximab) Frequently Asked Questions

Ontario Public Drug Programs. Inflectra (infliximab) Frequently Asked Questions Ontario Public Drug Programs Inflectra (infliximab) Frequently Asked Questions 1. What is the funding status of Inflectra (infliximab)? Effective February 25 2016, Inflectra (infliximab) will be added

More information

Prior Authorization. Physician Name: Specialty: NPI Number: Physician Fax: Physician Phone: Physician Address: City, State, Zip:

Prior Authorization. Physician Name: Specialty: NPI Number: Physician Fax: Physician Phone: Physician Address: City, State, Zip: 12/16/2015 Prior Authorization AETA BETTER HEALTH OF TEXAS MEDICAID Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

Medication Policy Manual. Topic: Otezla, apremilast Date of Origin: May 9, 2014

Medication Policy Manual. Topic: Otezla, apremilast Date of Origin: May 9, 2014 Medication Policy Manual Policy No: dru342 Topic: Otezla, apremilast Date of Origin: May 9, 2014 Committee Approval Date: January 19, 2015 Next Review Date: January 2016 Effective Date: April 1, 2015 IMPORTANT

More information