2. Is the patient responding to Remicade therapy? Y N
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- Doreen Harris
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1 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 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 Remicade (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) Remicade (infliximab) 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 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 3.] 2. Is the patient responding to Remicade therapy? [o further questions.] 3. Will the patient be concurrently receiving live vaccines, other TF- inhibitors or Kineret? [If yes, no further questions.] 4. Initial Authorization: Fistulizing Crohn s Disease. Does the patient meet ALL of the following? or o
2 Diagnosis is Fistulizing Crohn s Disease \ Treatment is prescribed by, or in consultation with a gastroenterologist \ Patient is at least 18 years old [If yes, no further questions.] Circle es or o 5. Initial Authorization: Crohn s Disease. Does the patient meet ALL of the following? Diagnosis is moderate to severe active Crohn s Disease (CD) \ Treatment is prescribed by, or in consultation with a gastroenterologist \ Patient is at least 6 years old [If no, skip to question 11.] 6. Does the patient meet OE of the following? Please indicate which contraindication/intolerance to corticosteroids, list Trial and failure of a compliant regimen of oral corticosteroids (for moderate to severe CD) or intravenous corticosteroids (for severe and fulminant CD) for one month OR \ Patient has contraindication or intolerance to PO or IV corticosteroids. 7. Does the patient meet OE of the following? Please indicate which contraindication/intolerance to azathioprine or mercaptopurine, list Trial and failure of a compliant regimen of azathioprine or mercaptopurine for 3 consecutive months OR \ Patient has contraindication or intolerance to azathioprine or mercaptopurine. 8. Does the patient meet OE of the following? Please indicate which contraindication/intolerance to Humira, list Trial and failure of a compliant regimen of Humira for 3 consecutive months OR \ Patient has contraindication or intolerance to Humira.
3 Circle es or o 9. Is the patient an adult? 10. Has the patient had a trial and failure of parenteral methotrexate? [o further questions.] 11. Initial Authorization: Ulcerative Colitis. Does the patient meet ALL of the following? Diagnosis is moderate to severe active Ulcerative Colitis \ Treatment is prescribed by, or in consultation with a gastroenterologist \ Patient is at least 6 years old [If no, skip to question 17.] 12. Does the patient meet OE of the following? Please indicate which contraindication/intolerance to aminosalicylates, list Trial and failure of a compliant regimen of oral or rectal aminosalicylates (i.e., sulfasalazine or mesalamine) for 2 consecutive months OR \ Patient has contraindication or intolerance to aminosalicylates. 13. Does the patient meet OE of the following? Please indicate which contraindication/intolerance to corticosteroids, list Trial and failure of a compliant regimen of oral or intravenous corticosteroid therapy for 1 month OR \ Patient has contraindication or intolerance to corticosteroids. 14. Does the patient meet OE of the following? Please indicate which contraindication/intolerance to azathioprine or mercaptopurine, list
4 Trial and failure of a compliant regimen of azathioprine or mercaptopurine for 3 consecutive months OR \ Patient has contraindication or intolerance to azathioprine or mercaptopurine. Circle es or o 15. Is the patient an adult? 16. Has the patient failed a compliant trial of Humira for at least 2 months? [o further questions.] 17. Initial Authorization: Rheumatoid Arthritis (RA). Does the patient meet ALL of the following? Diagnosis is moderate to severe rheumatoid arthritis \ Treatment is prescribed by, or in consultation with a rheumatologist \ Patient is at least 18 years old [If no, skip to question 21.] 18. Does the patient meet OE of the following? Please indicate which contraindication to methotrexate, list contraindication): Remicade will be given in combination with methotrexate OR \ Patient has contraindication or intolerance to methotrexate. 19. Has the patient met OE of the following? Please indicate which of the below apply to patient (if patient has contraindication/intolerance to 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 a contraindication or intolerance to methotrexate and other DMARDs
5 20.Does the patient meet OE of the following? Please indicate which Circle es or o months OR \ Patient has contraindication or intolerance to Enbrel and Humira 21. Initial Authorization: Ankylosing Spondylitis. Does the patient meet ALL of the following? Diagnosis is Ankylosing Spondylitis \ Treatment is prescribed by, or in consultation with a rheumatologist \ Patient is at least 18 years old [If no, skip to question 24.] 22.Does the patient meet OE of the following? Please indicate which contraindication/intolerance to SAIDs, list Trial and failure of a compliant regimen of two formulary SAIDs within the last 60 days OR \ Patient has contraindication or intolerance to SAIDs. 23.Does the patient meet OE of the following? Please indicate which consecutive months OR \ Patient has contraindication or intolerance to Enbrel and Humira. [o further questions.] 24.Initial Authorization: Plaque Psoriasis. Does the patient meet ALL of the following?
6 Circle es or o Diagnosis is chronic severe Plaque Psoriasis \ Treatment is prescribed by, or in consultation with a dermatologist \ Patient is at least 18 years old [If no, skip to question 28.] 25.Does the patient meet OE of the following? Please indicate which contraindication to UVB and PUVA, list contraindication): ial and failure of phototherapy (UVB or PUVA),OR \ Patient has contraindication to phototherapy (UVB and PUVA) 26.Does the patient meet OE of the following? Please indicate which contraindication/intolerance to methotrexate, list Trial and failure of a compliant regimen of methotrexate for 3 consecutive months, OR \ Patient has a contraindication/intolerance to use of methotrexate. 27.Does the patient meet OE of the following? Please indicate which consecutive months OR \ Patient has contraindication or intolerance to Enbrel and Humira. [o further questions.] 28. Initial Authorization: Psoriatic Arthritis. Does the patient meet ALL of the following? Diagnosis is moderate to severe psoriatic arthritis \ Treatment is prescribed by, or in consultation with a dermatologist or rheumatologist \ Patient is at least 18 years old
7 29. Does the patient meet OE of the following? Please indicate which contraindication/intolerance to methotrexate, list Circle es or o Trial and failure of a compliant regimen of methotrexate for at least 3 months OR \ Patient has contraindication or intolerance to methotrexate. 30. Does the patient meet OE of the following? Please indicate which months OR \ Patient has contraindication or intolerance to Enbrel and Humira. [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,
More informationCircle 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 information2. 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 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
More information2. 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 information3. 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
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More information3. 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
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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
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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 information2. Does the patient have a diagnosis of giant cell arteritis (GCA)? Y N
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More information3. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing for giant cell arteritis?
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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 information2. Is the patient responding to medication? Y N
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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
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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
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More information3. Has bone specific alkaline phosphatase level increased OR does the member have symptoms related to active Paget s?
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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
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More information3. 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 information2. 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
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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
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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
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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 information2. 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 information3. 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
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More information[If yes, no further questions.]
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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 8 Last Review Date: March 17, 2017 Simponi / Simponi
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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
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