EVALUATION OF USE OF BELIMUMAB IN CLINICAL PRACTICE SETTINGS PATIENT CASE RECORD FORM PHASE II, MONTH PATIENT FOLLOW-UP
|
|
- Roderick Derek Austin
- 5 years ago
- Views:
Transcription
1 EVALUATION OF USE OF BELIMUMAB IN CLINICAL PRACTICE SETTINGS PATIENT CASE RECORD FORM PHASE II, MONTH PATIENT FOLLOW-UP NOTE: Important Definition of Study Treatment Period Please provide patient information only for the period between month 18 and month 24 post belimumab therapy initiation. Based on data previously submitted in Phase I, the post-belimumab therapy initiation followup time period of months 18 to 24 for this patient is: FROM: TO: MD OFFICE ID #: (MDA ASSIGNED) PATIENT ID #: PATIENT GENDER: PATIENT ETHNICITY: BELIMUMAB START DATE: Did this patient experience any adverse event(s) related to belimumab between and? 2 No 1 Yes If Yes, please provide a description of the adverse experience(s) including the date of the event, belimumab dose at the time of event, and if the event was resolved / unresolved. If the patient died, please include cause of death and all relative details. Adverse Event 1: Date of event #1: M D Y Belimumab dose at the time of the event: Was this adverse event resolved? Yes 1 No 2 Did this patient die? No 2 Yes 1 Continue below If this patient died, what was the cause of death: If this patient died, what was the date of death: M D Y Adverse Event 2: Date of event #2: M D Y Belimumab dose at the time of the event: Was this adverse event resolved? Yes 1 No 2 Did this patient die? No 2 Yes 1 Continue below If this patient died, what was the cause of death: If this patient died, what was the date of death: M D Y SLE PATIENT CRF v8 August 15, 2012 PHASE II_FU Page 1
2 SECTION I: PATIENT PROFILE 1. Current weight: _ 1 lbs 2 kg SECTION II: CURRENT BELIMUMAB THERAPY 2. Is this patient still on belimumab therapy? 1 Yes Skip to Q3 2 No / / _ Answer below: If belimumab therapy ended, specify reasons for ending therapy [ x all that apply]: 1 Disease progression 4 Patient request 2 Medication not effective 5 Loss of insurance or reimbursement 3 Lack of compliance 6 Lost to follow-up or death x Adverse Event (SPECIFY): x Other (SPECIFY): 3. Specify the LAST or MOST RECENT DOSE of belimumab (at 24 months post-initiation or at time of discontinuation): mg/kg 4. Any CHANGES to the belimumab dose between and or date of discontinuation? 2 No Skip to Q5 1 Yes # of dose changes? Please indicate the date, dose, and reason for each dose change below: Date: 1 st : / / New Dose: _mg/kg Reason (SPECIFY): Date: 2 nd : / / New Dose: _mg/kg Reason (SPECIFY): Date: 3 rd : / / New Dose: _mg/kg Reason (SPECIFY): 5. What is your overall clinical assessment of disease severity of this patient at the end of month 18 (as of ) post belimumab therapy initiation? ( X one only) 0 Not documented SLE PATIENT CRF v8 August 15, 2012 PHASE II_FU Page 2
3 SECTION III: SLE CLINICAL MANIFESTATIONS, SEVERITY, AND IMPROVEMENT ASSESSMENT BETWEEN MONTHS 18 AND 24 POST BELIMUMAB THERAPY INITIATION 6. Complete table below based on the period of months following the start of belimumab therapy on:. PLEASE NOTE: This section pertains only to the 6-month period between and ; NOT from initiation to current. CLINICAL ASSESSMENT BETWEEN MONTH 18 AND MONTH 24 POST BELIMUMAB THERAPY INITIATION SLE Clinical Manifestations at Start of month 18 (Use # Codes In Legend Sheet. Use one row for each clinical manifestation) Code #: Code #: Code #: Code #: Code #: Code #: Other (SPECIFY): Severity of Clinical Manifestation at start of month 18 ( X one only for each) % Improvement in Individual Clinical Manifestations from months 18 to 24 (or date of ( X one only for each manifestation ) OVERALL CLINICAL RESPONSE to belimumab: during months 18 to 24 (or to Clinician impression of overall clinical manifestations observed: ( X one only) 1 Deteriorated 2 No Improvement 3 <20% Improvement % Improvement % Improvement 6 >80% Improvement SECTION IV: SLE DISEASE ACTIVITY ASSESSMENT BETWEEN MONTHS 18 AND 24 POST BELIMUMAB THERAPY INITIATION 7. Did you use any of the disease activity assessment tools listed below for this patient to be able to provide assessments at end of month 24 (as of, or date of post belimumab therapy initiation? ( X one only) 1 Yes Complete table below 2 No Skip to Q8 Q7b. Assessment at the end of month 24 post belimumab initiation (or at date of YES, tool used ( X box below) Score Physician Global Assessment Scale Specify range of scale used: to 1 _ Patient Global Assessment Scale Specify range of scale used: to 2 _ SELENA-SLEDAI (Systemic Lupus Erythematosus Disease Activity Index SELENA Modification) / SLEDAI) 3 _ BILAG (British Isles Lupus Assessment Group Index) 4 _ SLAM (Systemic Lupus Activity Measure) 5 _ ECLAM (European Consensus Lupus Activity Measurement Index) 6 _ Other (SPECIFY): _ x _ 8. Did you use any other assessment tools for this patient at the end of month 24 (as of ) post belimumab therapy initiation? ( X one only) SLE PATIENT CRF v8 August 15, 2012 PHASE II_FU Page 3
4 1 Yes Complete table below 2 No Skip to Q9 Q8b. Assessment at the end of month 24 post belimumab initiation (or at date of Fatigue Severity Scale Please normalize the scale/score to a range of and provide your assessment YES, tool used ( X box below) 1 Score Other (SPECIFY): _ x SECTION V: OTHER SLE THERAPIES PRESCRIBED/USED BETWEEN MONTHS 18 & 24 POST BELIMUMAB THERAPY INITIATION 9. Was this patient prescribed other SLE medications, other than belimumab, between months 18 & 24 post belimumab therapy initiation? ( X one only) 1 Yes Complete table below 2 No Skip to Q10 Q.9a SLE medications [CONTINUED FROM PREVIOUS TREATMENT PERIOD used between and. Medication (use Legend # codes) Medication (use Legend # codes) Dose per Administration Medication (use Legend # codes) Medication (use Legend # codes) Route of Administration Frequency x Other: x Other: x Other: x Other: SLE PATIENT CRF v8 August 15, 2012 PHASE II_FU Page 4
5 Q.9b SLE medications [NEWLY STARTED] between and. Dose per Administration Route of Administration Frequency Medication (use Legend # codes) At the time of medication start 4 Once a week 5 Every 2 weeks x Other: 1 Daily 2 BID 4 Once a week 3 TID 5 Every 2 weeks Medication (use Legend # codes) At the time of medication start Medication (use Legend # codes) At the time of medication start x Other: x Other: x Other: 4 Once a week 5 Every 2 weeks x Other: x Other: SECTION VI: SLE-RELATED RESOURCE UTILIZATION 10. How many scheduled and unscheduled SLE-related office visits did this patient have between and or the date of belimumab discontinuation? (Record below) SLE RELATED PATIENT VISITS TO YOUR OFFICE # of Scheduled SLE-related visits to your office: # of Unscheduled SLE-related visits to your office: Between months 18 & 24 (or date of post belimumab therapy initiation (ENTER 0 IF NONE DOCUMENTED) SLE PATIENT CRF v8 August 15, 2012 PHASE II_FU Page 5
6 11. Between and (or the date of, which other physician specialties, if any, did this patient see for SLE-related reasons? Complete the number of visits for each specialty seen in table below. SPECIALISTS VISITED FOR SLE-RELATED REASONS [ X all that apply] 1 Another Rheumatologist 2 Allergist 3 Cardiologist 4 Dermatologist 5 Gastroenterologist 6 Internist 7 Nephrologist 8 Neurologist 9 Ophthalmologist 10 Psychologist 11 Radiologist x Other (Please Specify): Between months 18 & 24 (or date of post belimumab therapy initiation (ENTER 0 IF NONE DOCUMENTED) 12. Has this patient had at least one Emergency Room (ER) visit related to SLE between and or the date of belimumab discontinuation? ( X one only) 1 Yes Complete table below 2 No Skip to Q13 Q18b ER visits related to SLE Between months 18 & 24 (or date of belimumab discontinuation) post belimumab therapy initiation (ENTER 0 IF NONE DOCUMENTED) # of ER visits: 13. Has this patient had at least one SLE-related hospitalization between and or the date of belimumab discontinuation? ( X one only) 1 Yes Complete table below 2 No Skip to Q14 Q13b Hospitalization # 1 Hospitalization # 2 Hospitalization # 3 Hospitalization # 4 Admission date Mo Day Yr Mo Day Yr Mo Day Yr Mo Day Yr ICD-9 Code Related to belimumab? 1 Yes 1 Yes 1 Yes 1 Yes # Hospital days # # # # Admitted to ICU SLE PATIENT CRF v8 August 15, 2012 PHASE II_FU Page 6
7 14. Did this patient receive any SLE-related ancillary care between and or the date of belimumab discontinuation? ( X one only) 1 Yes Complete table below Q14b SLE-RELATED ANCILLARY CARE Physical therapy Occupational therapy Home health care services Other (Specify): 2 No Skip to Q15 Between months 18 & 24 (or date of post belimumab therapy initiation 15. Did this patient s primary or secondary medical or prescription drug insurance coverage change between months 18 and 24 post belimumab initiation? If yes, please indicate the patient s major medical insurance (Column A) and prescription drug insurance coverage (Column B) in the table below, at the end of month 24 (as of ) post belimumab initiation, or at the date of belimumab discontinuation. ( X one only) 1 Yes Complete table below 2 No Please complete the remaining Patient CRFs. INSURANCE COVERAGE CHANGE between and Column A: Medical Insurance Coverage Column B: Drug Insurance Coverage Primary Secondary Primary Secondary Medicare (including office injection) Medicaid State Funded Program Traditional Fee For Service/Indemnity Insurance HMO PPO Self Pay Indigent / No Pay VA None Don t Know / Not documented END OF THIS PATIENT CRF. PLEASE COMPLETE THE REMAINING PATIENT CRFs. SLE PATIENT CRF v8 August 15, 2012 PHASE II_FU Page 7
Licking County Health Department Health Care Access Assessment
Licking County Health Department 0 Health Care Access Assessment Figure : Geographic distribution of health care providers Legend!( URGENT CARE!( PEDIATRICIAN!( ONCOLOGIST!( FAMILY PHYSICIAN!( DENTISTS
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
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 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
More information2. 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 informationLONGITUDINAL TREATMENT PATTERNS AND ASSOCIATED OUTCOMES IN PATIENTS WITH NEWLY DIAGNOSED SYSTEMIC LUPUS ERYTHEMATOSUS. Hong Kan 7/12/2016
LONGITUDINAL TREATMENT PATTERNS AND ASSOCIATED OUTCOMES IN PATIENTS WITH NEWLY DIAGNOSED SYSTEMIC LUPUS ERYTHEMATOSUS Hong Kan 7/12/2016 1 Acknowledgements Research conceptualization and design, programming
More information3. 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 information2. 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 informationClinical Commissioning Policy Statement: Rituximab For Systemic Lupus Erythematosus (SLE) December Reference : NHSCB/A3C/1b
Clinical Commissioning Policy Statement: Rituximab For Systemic Lupus Erythematosus (SLE) December 2012 Reference : NHSCB/A3C/1b NHS Commissioning Board Clinical Commissioning Policy Statement: Rituximab
More information2. 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 informationMarket Access CTR Summary
Market Access CTR Summary Study No.: BEL114246 Title: Efficacy of Belimumab Treatment in a Subpopulation of Systemic Lupus Erythematosus (SLE) Patients: A Pooled Analysis of the HGS1006-C1056 (BLISS-52)
More informationCircle 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[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 informationCircle 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 informationGender: Male Female Age: Current Address: City: State: Zip Code: Work Phone: Is it okay to leave a message? VISIT INFORMATION
SIENA PROACTIVE INTERNAL MEDICINE DR. DEBORAH BLENNER 45 Terry Road, Suite B Smithtown, NY 11787 www.sienaproactive.com Phone: (631) 656-8171 Fax: (631) 656-8173 PATIENT INFORMATION Last Name: First Name:
More informationREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: Anthem Blue Cross Cal MediConnect Plan 1-844-493-9213 Medicare Prior Authorization
More information3. 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 informationTYPES OF DOCTORS. Dermatologist - This is a doctor that treats any ailment related to the skin and its appendages such as hair, nails etc.
Cardiologist - A cardiologist is certified to treat any problem dealing with heart diseases and cardiovascular diseases. Dentist - Any dental problem from tooth decay to dentures to retainers are handled
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 informationHUSKY Health Benefits and Prior Authorization Requirements Grid* Behavioral Health Partnership Effective: January 1, 2012
Behavioral Health Health and Behavior Assessments (CPT 96150-96155) When Performed by Psychologists Mental Health Inpatient 100% covered under medical benefit for members with diagnoses outside the range
More informationTaming the wolf: Treating to target, treating to remission new strategies for SLE
Taming the wolf: Treating to target, treating to remission new strategies for SLE Ronald van Vollenhoven Seattle, April 28, 2017 Disclosures Research support, consultancy: Abbott (AbbVie), Biotest, BMS,
More informationCPT Code Changes for 2013 Frequently Asked Questions Last Updated 12/2/2012
1. Why are CPT codes changing? CPT Code Changes for 2013 Frequently Asked Questions Last Updated 12/2/2012 CPT code changes occur every year. The Current Procedural Terminology, or CPT, code set is maintained
More informationCurricular Components for Rheumatology EPA
Curricular Components for Rheumatology EPA 1. EPA Title Manage patients with acute or chronic complex multi-system rheumatic disease in an ambulatory, emergency, or inpatient setting. 2. Description of
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. 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 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 informationURINE DRUG TESTING FOR SUBSTANCE ABUSE TREATMENT AND CHRONIC PAIN MANAGEMENT
Status Active Medical and Behavioral Health Policy Section: Laboratory Policy Number: VI-47 Effective Date: 07/21/2014 Blue Cross and Blue Shield of Minnesota medical policies do not imply that members
More informationPharmaceutical Management Medicaid 2019
Pharmaceutical Management Medicaid 2019 Toll-free Contact Number: (888) 327-0671 Pharmacy Administration: (810) 244-1660 Introduction Pharmaceutical Management promotes the use of the most clinically appropriate,
More informationPrincipal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19)
Benefit Summary 35876D 35876 SCHOOLS INSURANCE GROUP #35876 Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19) Plan Out-of-Pocket Maximum For Services subject
More informationADMINISTRATIVE POLICY AND PROCEDURE
Page 1 of 5 SECTION: Medical SUBJECT: Neuropsychological and Psychological Testing DATE OF ORIGIN: 2/13/13 REVIEW DATES: 7/17/15 EFFECTIVE DATE: 12/15/16 APPROVED BY: EXECUTIVE DIRECTOR MEDICAL DIRECTOR
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 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 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 informationWhich outcome measures in SLE clinical trials best reflect medical judgment?
To cite: Thanou A, Chakravarty E, James JA, et al. Which outcome measures in SLE clinical trials best reflect medical judgment? Lupus Science & Medicine 2014;1:e000005. doi:10.1136/lupus-2013-000005 Received
More informationCHRONIC MEDICINE PROGRAMME: GENERAL INFORMATION LETTER
CHRONIC MEDICINE PROGRAMME: GENERAL INFORMATION LETTER The Prescribed Minimum Benefit Chronic Disease List In terms of the Medical Scheme Act Regulations that came into effect on 1 January 2004, Medical
More informationWITBANK COALFIELDS MEDICAL AID SCHEME (WCMAS) CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER
WITBANK COALFIELDS MEDICAL AID SCHEME (WCMAS) CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER The Prescribed Minimum Benefit Chronic Disease List In terms of the Medical Scheme Act Regulations that
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
More informationThe Third-Party Reimbursement Process for Orthotics
The Third-Party Reimbursement Process for Orthotics When the foot hits the ground, everything changes. We know that over 90% of the population suffers with overpronation of their feet. Implementing Foot
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
More information3. 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 informationNo An act relating to health insurance coverage for early childhood developmental disorders, including autism spectrum disorders. (S.
No. 158. An act relating to health insurance coverage for early childhood developmental disorders, including autism spectrum disorders. (S.223) It is hereby enacted by the General Assembly of the State
More informationSpotting Cancer Survey Questions
Q1a. Please indicate to what extent you agree or disagree with the following statement. Knowing the major signs and symptoms for cancer can help to detect the disease. 1 Disagree completely 5 Agree completely
More information2. 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 information2. 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 informationPATIENT SIGNATURE: DOB: Date:
CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have received a copy of CPP s Notice of Privacy Practices. The Notice
More informationIcd 10 code for employment drug screen Icd 10 code for employment drug screen
Icd 10 code for employment drug screen Icd 10 code for employment drug screen The 2018/2019 edition of ICD-10-CM Z02.83 became effective on October 1, 2018. Z02.2 Encounter for examination for admission
More informationHealth Indicators in Curaçao
Health Indicators in Curaçao 2018 Health Indicators in Curaçao 2018 This is a publication of: Volksgezondheid Instituut Curaçao (VIC) Ministry of Health, Environment and Nature Molenplein z/n, Otrobanda,
More informationPharmacy 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 informationNICE: Single technology appraisal: Belimumab for the treatment of active auto-antibody systemic lupus erythematosus (April 2012)
LUPUS UK, St James House, Eastern Road, Romford Essex RM1 3NH Tel: 01708 731251 visit our website www.lupusuk.org.uk NICE: Single technology appraisal: Belimumab for the treatment of active auto-antibody
More informationReport to the Social Services Appropriations Subcommittee
Report to the Social Services Appropriations Subcommittee Medicaid Coverage and Reimbursement for Outpatient Physical Therapy and Outpatient Occupational Therapy Prepared by the Division of Medicaid and
More informationValue of Hospice Benefit to Medicaid Programs
One Pennsylvania Plaza, 38 th Floor New York, NY 10119 Tel 212-279-7166 Fax 212-629-5657 www.milliman.com Value of Hospice Benefit May 2, 2003 Milliman USA, Inc. New York, NY Kate Fitch, RN, MEd, MA Bruce
More informationResearch Article Performance Characteristics of Different Anti-Double-Stranded DNA Antibody Assays in the Monitoring of Systemic Lupus Erythematosus
Hindawi Immunology Research Volume 217, Article ID 17292, pages https://doi.org/.11/217/17292 Research Article Performance Characteristics of Different Anti-Double-Stranded DNA Antibody Assays in the Monitoring
More information* Autoantibody positive (i.e. antinuclear antibody or ANA titre 1:80 or anti-double stranded (ds) DNA antibody 30 IU/mL)
Benlysta (belimumab) Policy Number: 5.02.509 Last Review: 05/2018 Origination: 06/2011 Next Review: 05/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for Benlysta
More informationPharmacy 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 informationPharmacy Medical Policy IgE Receptor Binding Inhibitors
Pharmacy Medical Policy IgE Receptor Binding Inhibitors Table of Contents Policy: Commercial Policy History Endnotes Policy: Medicare Information Pertaining to All Policies Forms Coding Information References
More informationFINAL TOPLINE. Diabetes Group. Qualities That Matter: Public Perceptions of Quality in Diabetes Care, Joint Replacement and Maternity Care
FINAL TOPLINE Group Qualities That Matter: Public Perceptions of Quality in Care, Joint Replacement and Maternity Care National Survey of adults recently diagnosed with type 2 diabetes about their perceptions
More informationCHRONIC MEDICINE PROGRAMME: PICK N PAY PLUS OPTION - GENERAL INFORMATION LETTER
CHRONIC MEDICINE PROGRAMME: PICK N PAY PLUS OPTION - GENERAL INFORMATION LETTER Prescribed Minimum Benefits The prescribed minimum benefits (PMBs) comprise a list of 270 conditions or group of conditions
More informationMonitoring Physical Activity in a Form that is Meaningful for Patients and Providers Enrolled in a Weight Management Program
Monitoring Physical Activity in a Form that is Meaningful for Patients and Providers Enrolled in a Weight Management Program Joseph E. Donnelly, ED.D., FACSM, FTOS Professor, Internal Medicine Director,
More informationTechnology appraisal guidance Published: 22 June 2016 nice.org.uk/guidance/ta397
Belimumab for treating active autoantibody-positive systemic lupus erythematosus Technology appraisal guidance Published: 22 June 2016 nice.org.uk/guidance/ta397 NICE 2018. All rights reserved. Subject
More informationMY PERSONAL HEALTHCARE RECORD. A great way to keep your. healthcare & medication. information in one place. Remember to take this
A great way to keep your MY PERSONAL HEALTHCARE healthcare & medication information in one place RECORD Remember to take this with you to all of your hospital & doctor visits Our Community Your Health
More informationPLEASE FILL OUT & RETURN
PLEASE FILL OUT & RETURN MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM CONSENT and AUTHORIZATION for RELEASE of INFORMATION I agree to participate in the Medication Therapy Management (MTM) Program. I will
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 information1. 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 informationRetinal Consultants of San Antonio PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Referred by Patient Full Name Home Address City State Zip Code Home Phone Cell Phone E-mail address Date of Birth Preferred Method of Contact: Home Phone / Cell Phone
More informationCircle 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 informationThank you for being a Premera Blue Cross Medicare Supplement plan member.
P.O. Box 327 Seattle, WA 98111 February 18, 2019 MSF1 Dear : Thank you for being a Premera Blue Cross Medicare Supplement plan member. The rate table on the next page shows the following rate information:
More informationPharmacy 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 informationDefinition Chronic autoimmune disease The body s immune system starts attacking itself Can affect most organs and tissues in the body Brain, lungs, he
LIVING WITH SYSTEMIC LUPUS ERYTHEMATOSUS Stacy Kennedy, M.D.,M.B.A. Rowan Diagnostic Clinic Salisbury, N.C. May 11, 2013 Agenda What is lupus Who is affected Causes of lupus Symptoms and organ involvement
More informationa guide to Reimbursement of Intermittent Catheters Know your options M2116N 04.08
a guide to Reimbursement of Intermittent Catheters 1 Know your options Coloplast Corp. Minneapolis, MN 55411 1.800.533.0464 usmedweb@coloplast.com www.us.coloplast.com is a registered trademark of Coloplast
More informationUsing claims data to investigate RT use at the end of life. B. Ashleigh Guadagnolo, MD, MPH Associate Professor M.D. Anderson Cancer Center
Using claims data to investigate RT use at the end of life B. Ashleigh Guadagnolo, MD, MPH Associate Professor M.D. Anderson Cancer Center Background 25% of Medicare budget spent on the last year of life.
More information3. 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 informationPharmacy 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 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 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 information3. 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 informationNutrition Packet INFORMATION FOR THE DAY OF YOUR APPOINTMENT
Nutrition Packet Enclosed is a packet of information for you to fill out and bring with you to your appointment. But first, a few important details before we meet: INFORMATION FOR THE DAY OF YOUR APPOINTMENT
More informationORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION
UnitedHealthcare Community Plan Medical Benefit Drug Policy ORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION Policy Number: CS2018D0039J Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS
More informationGuidelines for Visit 42
Guidelines for Visit 42 Table of Contents Form Page(s) Section 4 Appendix 1: Cancer Site Codes... 28 Appendix 2: Tissue Biopsy Sites... 30 Appendix 3: Diagnosis of Tissue... 31 Appendix 4: Neurological
More informationPain Relief Recover from Injury Chiropractic Therapeutic Laser Therapy. Release & Balance Method Nutritional Counseling Laboratory Testing & Analysis
Health Solutions Center John Gangemi Chiropractic Physician Date Date of Birth Name Mailing Address Home Phone Cell Occupation Email How Did You Hear About Our Office Whom May We Thank For Referring You
More informationNew patients approved for the Novo Nordisk PAP may only be eligible for insulin vials. For a full list of available products, please visit:
The Novo Nordisk Diabetes Patient Assistance Program (PAP) provides medication to qualifying applicants at no charge. If the applicant qualifies under the Novo Nordisk Diabetes PAP guidelines, a 120-day
More informationCircle 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 informationGalafold (migalastat) or Fabrazyme (agalsidase beta) Prior Authorization Criteria:
Request for Prior Authorization for Fabry Disease Medications Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for Galafold (migalastat) or Fabrazyme (agalsidase
More informationPharmacy 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 information3. 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 informationCommittee Approval Date: May 9, 2014 Next Review Date: May 2015
Medication Policy Manual Policy No: dru248 Topic: Benlysta, belimumab Date of Origin: May 13, 2011 Committee Approval Date: May 9, 2014 Next Review Date: May 2015 Effective Date: June 1, 2014 IMPORTANT
More informationNavigating the Table of Drugs & Chemicals
Navigating the Table of Drugs & Chemicals Poisoning Defined drugs given in error (wrong drug) medication given in error (wrong dose, wrong patient, wrong route of administration) overdose of a drug given
More informationPrincipal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19)
Disclosure Form SISC - Self Insured Schools Of California Home Region: California Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19) Accumulation Period The Accumulation Period
More informationhttp://results.harrispollonline.com/surveyresults/default.asp?file=page1.html In general, how would you describe your own health? 16% 34% 29% 13% 7% Excellent Very good Good Fair Poor http://results.harrispollonline.com/surveyresults/default.asp?file=page2.html
More informationSECTION 4: RECRUIT PARTICIPANTS
SECTION 4: RECRUIT PARTICIPANTS Contents Participant Eligibility & Enrollment... 2 Screening... 2 Study ID Numbers... 2 Inclusion Criteria... 2 Exclusion Criteria... 4 Co-Enrollment... 5 Informed Consent
More informationMEDICAL POLICY I. POLICY POLICY TITLE POLICY NUMBER CANAKINUMAB (ILARIS ) MP-2.147
Original Issue Date (Created): May 1, 2010 Most Recent Review Date (Revised): March 25, 2014 Effective Date: June 1, 2014 I. POLICY Preauthorization is required for injectable Canakinumab (Ilaris ): Note:
More informationApplied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder
Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder Policy Number: Original Effective Date: MM.12.022 01/01/2016 Line(s) of Business: Current Effective Date: HMO; PPO; Fed 87; FEP;
More informationCase Review of Inpatient Rehabilitation Hospital Patients Not Suited for Intensive Therapy
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES OFFICE OF INSPECTOR GENERAL Case Review of Inpatient Rehabilitation Hospital Patients Not Suited for Intensive Therapy OEI-06-16-00360 DECEMBER 2016 SUZANNE MURRIN
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: belimumab_benlysta 6/2011 2/2018 2/2019 3/2018 Description of Procedure or Service Belimumab (Benlysta) is
More informationProviderNews FEBRUARY
ProviderNews FEBRUARY 2017 Reminder: decimal billing required on time-based therapy codes for BadgerCare Plus members In accordance with Forward Health guidelines, Security Health Plan requires decimal
More information2. 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 informationSPECIAL REPORT: CPT CODES WHAT THERAPISTS NEED TO KNOW
Page1 PRICE: $10.00 SPECIAL REPORT: CPT CODES WHAT THERAPISTS NEED TO KNOW By Barbara Griswold, LMFT Author, Navigating the Insurance Maze: The Therapist s Complete Guide to Working With Insurance And
More informationORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION
ORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION UnitedHealthcare Commercial Medical Benefit Drug Policy Policy Number: 2018D0039J Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS
More informationComprehensive support for your patients on MYALEPT
Comprehensive support for your patients on MYALEPT Insurance and financial assistance options (see page 3) Fulfillment support (see page 6) Co-pay assistance a,b (see page 4) Your patient Injection training
More informationOpioid Treatment Center Application
PLEASE FILL OUT ALL AREAS COMPLETLY Name: Date: Maiden Name or Aliases: Address: Phone: Date of Birth: SSN#: Gender: Male Female Referral Source: Phone #: Annual Family Income: SSDI SSI Other Income Insurance
More informationICD-10CM, HCC and Risk Adjustment Factor
ICD-10CM, HCC and Risk Adjustment Factor Not everyone is aware of what CMs calls the risk adjustment model. It was developed under the Patient Protection and Affordable Care Act (also known as the PACA)
More information