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.
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1 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 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 1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)? Circle es or o [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? [If no, skip to question 4.] 3. Was there evidence of clinical remission by week 8 of therapy? [If yes, skip to question 5.]
2 4. Has documentation been submitted showing that the patient continues to have a beneficial response to therapy with Humira? Circle es or o 5. Has the patient been compliant with therapy? 6. Will the patient be receiving additional therapy with another biologic DMARD? [o further questions.] 7. Has documentation of all of the following been submitted? A) Diagnosis, treatment history and dose, B) Age, C) Weight for pediatric patients, D) egative TB test within the last 12 months, and E) Confirmation that the patient does not have heart failure. [o further questions.] 8. Is the request for an adult patient with a diagnosis of rheumatoid arthritis or psoriatic arthritis [If no, skip to question 11.] 9. Has the patient had a trial and failure of methotrexate and at least 1 other non-biologic DMARD (sulfasalazine, cyclosporine, hydroxychloroquine or leflunomide) as sequential monotherapy for 3 months each or in combination for at least 3 months? [If yes, skip to question Does the patient have a documented contraindication/intolerance to methotrexate and other DMARDs? 11. Is the request for a patient 18 years of age or older with a diagnosis of ankylosing spondylitis? [If no, skip to question 15.] 12. Has documentation been submitted showing that active disease has been present for at least 4 weeks?
3 13. Has documentation been submitted showing that the patient has a BASDAI score of 4 or more? Circle es or o 14. Has the patient had a trial and failure of 2 different SAIDs, steroid products, sulfasalazine or methotrexate? 15. Does the patient have a diagnosis of plaque psoriasis? [If no, skip to question 22.] 16. Does the plaque psoriasis involve greater than 10% of body surface area and/or the palms, soles, head, neck or genitalia? 17. Has the patient had a trial and failure of methotrexate for 3 consecutive months? [If yes, skip to question 19.] 18. Does the patient have a contraindication/intolerance to methotrexate? 19. Has the patient had a trial and failure of, or intolerance to, a topical agent or topical immunomodulator or other systemic therapies (e.g., cyclosporine or acitretin)? 20. Has the patient had a trial and failure of UVB or UVA therapy? 21. Does the patient have a contraindication to UVB and PUVA therapy?
4 22. Does the patient have a diagnosis of juvenile idiopathic arthritis? Circle es or o [If no, skip to question 28.] 23. Is the patient 2 years of age or older? 24. Has the patient had a trial and failure of at least 3 consecutive months of methotrexate? [If yes, skip to question 26.] 25. Does the patient have a documented contraindication/intolerance to methotrexate? 26. Has the patient had a trial and failure of at least one other non-biologic DMARD for 3 months? 27. Does the patient have a documented contraindication/intolerance to other DMARDs? 28. Is the request for a pediatric patient 6 years of age or older with a diagnosis of Crohn s disease? [If no, skip to question 30.] 29. Has the patient had an inadequate response to all of the following? A) corticosteroids, B) azathioprine, C) mercaptopurine, and D) methotrexate [If yes, skip to question 37.] 30. Does the patient have a diagnosis of Crohn s disease? [If yes, skip to question 32.] 31. Does the patient have a diagnosis of ulcerative colitis? [If no, skip to question 43.]
5 32. Has the patient had a trial and failure of parenteral methotrexate for 3 months? Circle es or o [If yes, skip to question 34.] 33. Does the patient have a contraindication/intolerance to methotrexate? 34. Has the patient had a trial and failure of oral or intravenous corticosteroids for at least one month? [If yes, skip to question 36.] 35. Does the patient have a contraindication/intolerance to corticosteroids? 36. Does the patient have a contraindication, intolerance, or a trial and failure of 2 or more of the following for 3 consecutive months? A) azathioprine, B) budesonide, C) oral or rectal aminosalicylates (eg, mesalamine, sulfasalazine, balsalazide disodium), D) cyclosporine, E) mercaptopurine, F) Remicade 37. Is Humira being requested for maintenance dosing more frequently than every other week? [If no, skip to question 46.] 38. Did the patient previously respond to Humira doses every other week? 39. Is the patient experiencing a flare that is likely to result in hospitalization? 40. Will therapy be resumed at every other week dosing after treatment of the flare?
6 41. Will the patient be receiving additional therapy with another biologic DMARD? Circle es or o [If yes, then no further questions.] 42. Is therapy being prescribed by, or in consultation with a gastroenterologist? [o further questions.] 43. Does the patient have a clinical diagnosis of moderate to severe hidradenitis suppurativa? 44. Has documentation of the use of the following general measures been submitted? A) Education and support, B) Avoidance of skin trauma, C) Hygiene, D) Dressings, E) Smoking cessation, F) Weight management, G) Diet. 45. Has the patient had a documented adequate trial and failure of infliximab (Remicade)? 46. Will the patient be receiving additional therapy with another biologic DMARD? [If yes, then no further questions.] 47. Is therapy being prescribed by, or in consultation with a rheumatologist, dermatologist, or gastroenterologist? [o further questions.] 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
3. 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. 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
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DRUG POLICY BENEFIT APPLICATION Remicade (infliximab) Inflectra (infliximab-dyyb) Renflexis (infliximab-abda) Benefit determinations are based on the applicable contract language in effect at the time
More informationCircle 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 informationBiologics 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 informationClinical Policy: Infliximab (Remicade, Inflectra, Renflexis) Reference Number: CP.PHAR.254
Clinical Policy: Infliximab (Remicade, Inflectra, Renflexis) Reference Number: CP.PHAR.254 Effective Date: 07/16 Last Review Date: 07/17 Coding Implications Revision Log See Important Reminder at the end
More informationCIMZIA (certolizumab pegol)
Pre - PA Allowance None Prior-Approval Requirements Age Diagnoses 18 years of age or older Patient must have ONE of the following: 1. Moderate to severe Crohn s Disease (CD) a. Inadequate response, intolerance
More informationClinical Policy: Ustekinumab (Stelara) Reference Number: ERX.SPMN.167
Clinical Policy: (Stelara) Reference Number: ERX.SPMN.167 Effective Date: 10/16 Last Review Date: 12/16 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More information2. 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 informationClinical 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 informationPharmacy Management Drug Policy
SUBJECT: Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn s Disease, Psoriatic Arthritis and Rheumatoid Arthritis POLICY NUMBER: PHARMACY-07 EFFECTIVE DATE: 5/2009 LAST REVIEW DATE: 6/13/2018
More informationRegulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 9 Last Review Date: March 16, 2018 Simponi / Simponi
More informationAmjevita (adalimumab-atto) CG-DRUG-64, CG-DRUG-65
Market DC Amjevita (adalimumab-atto) CG-DRUG-64, CG-DRUG-65 Override(s) Prior Authorization Quantity Limit Medications Amjevita 20 mg/0.4 ml prefilled syringe Amjevita (adalimumab-atto) 40 mg/0.8 ml 2
More informationProposal relating to the funding of TNF inhibitors (Humira and Enbrel) and gabapentin (Neurontin)
14 July 2015 Proposal relating to the funding of TNF inhibitors (Humira and Enbrel) and gabapentin (Neurontin) PHARMAC is seeking feedback on a proposal relating to the funding of the TNF-inhibitor medicines
More informationClinical Policy: Infliximab (Remicade) and Infliximab-dyyb (Inflectra) Reference Number: CP.PHAR.254
Clinical Policy: Infliximab (Remicade) and Infliximab-dyyb (Inflectra) Reference Number: CP.PHAR.254 Effective Date: 07/16 Last Review Date: 12/16 See Important Reminder at the end of this policy for important
More informationPrior 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 informationSee 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 informationDrugs and Applicable Coding: J-code: Enbrel-J1438; Humira-J0135; Remicade-J1745; Inflectra-Q5102; Cimzia-J0718; Simponi-J1602 Renflexis - pending
Policy Subject: Anti-TNF Agents Policy Number: SHS PBD16 Category: Rheumatology & Autoimmune Policy Type: Medical Pharmacy Department: Pharmacy Product (check all that apply): Group HMO/POS Individual
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