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

Transcription

1 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, sign and date. Fax signed forms to Aetna Better Health Kentucky at When conditions are met, we will authorize the coverage of Multiple Sclerosis Agents (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame Specify drug Quantity Frequency Strength Route of administration Expected length of therapy Patient information Patient name: Patient ID: Patient Group o.: Patient DOB: Patient phone: Prescribing physician Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: Circle the appropriate answer for each question. Question Circle es or o 1. Is the requested drug prescribed by or in consultation with a neurologist? 2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? [If no, skip to question 11.] 3. Is the member having a positive clinical response to the medication? 4. Have documentation and lab results as applicable to support the response to treatment (e.g., LVEF, CBC, AC, ECG, etc.) been submitted? Reference umber: C6578 A / Effective Date: 02/01/2018 1

2 Circle es or o 5. Is the renewal for Tysabri or Ocrevus? 6. Is the renewal for Aubagio, Gilenya, or Tecfidera? 7. Is the renewal for Lemtrada? [If no, skip to question 9.] 8. Has the member received more than 2 years of treatment with Lemtrada? If yes, please provide rationale for continued treatment: [o further questions] 9. Is the renewal for mitoxantrone? 10. Has the member received a cumulative lifetime dose of 140mg/m2? [o further questions.] 11. Is this a request for mitoxantrone? [If no, skip to question 21.] 12. Does the member have a diagnosis of relapsing-remitting multiple sclerosis (RRMS)? [If no, skip to question 14.] 13. Has the member had an inadequate response, intolerable side effects, or has a contraindication to 2 formulary agents, one of which must be a formulary interferon or glatiramer acetate agent? (see formulary for a list of preferred agents) ote: Examples of treatment failure include 2 or more relapses in one year or one severe relapse, MRI lesion progression (i.e., increase in T1, T2, or gadolinium lesions), worsening disability or EDSS score. List medications tried and description of failure: Reference umber: C6578 A / Effective Date: 02/01/2018 2

3 Circle es or o [If yes, skip to question 15.] 14. Does the member have a diagnosis of secondary (chronic) progressive MS (SPMS) or progressive relapsing MS (PRMS)? [If no, then no further questions] 15. Will all other multiple sclerosis medications (not including Ampyra) be discontinued before starting mitoxantrone? 16. Is the member at least 18 years old? 17. Has the member received a cumulative lifetime dose of 140mg/m2? 18. Has the member had an ECHOcardiogram (EKG) and a CBC within the past 6 months? 19. Was the LVEF (left ventricular ejection fraction) less than 50%? 20. Did the CBC show an AC less than 1500 cells/mm3? [o further questions.] 21. Does the member have a diagnosis of a relapsing form of multiple sclerosis (i.e., relapsing-remitting multiple sclerosis or secondary progressive multiple sclerosis)? [If yes, skip to question 26.] 22. Is this a request for Copaxone 40mg, Glatopa, Extavia or Avonex for a diagnosis of clinically isolated syndrome suggestive of multiple sclerosis (i.e. persons who have experienced a first clinical episode and have magnetic resonance imaging (MRI) features consistent with multiple sclerosis)? 23. Is this a request for Betaseron for a diagnosis of clinically isolated syndrome suggestive of multiple sclerosis (i.e. persons who have experienced a first Reference umber: C6578 A / Effective Date: 02/01/2018 3

4 Circle es or o clinical episode and have magnetic resonance imaging (MRI) features consistent with multiple sclerosis)? [If yes, skip to question 50.] 24. Is this a request for Ocrevus for a diagnosis of primary progressive multiple sclerosis (PPMS)? 25. Has the member been screened for hepatitis B and determined not to have an active hepatitis B infection? 26. Is the request for a preferred injectable agent? (refer to formulary for a list of preferred agents) 27. Is the request for a non-preferred injectable/infused agent? [If no, skip to question 39.] 28. Is the request for Betaseron or Plegridy? [If yes, skip to question 50.] 29. Is the request for Lemtrada? [If no, skip to question 32.] 30. Does the member have HIV infection? 31. Has the member already received a 2 year course of therapy with Lemtrada (5 days of treatment the first year and 3 days of treatment the second year)? [If no, skip to question 50.] 32. Is the request for Tysabri? [If no, skip to question 34.] 33. Has an anti-jcv antibody test (ELISA) been completed? Reference umber: C6578 A / Effective Date: 02/01/2018 4

5 Circle es or o ote: Those with positive anti-jcv antibody have a higher risk for developing progressive multifocal leukoencephalopathy (PML). [Go to question 50.] 34. Is the request for Zinbryta? [If no, skip to question 37.] 35. Have baseline serum transaminase levels (ALT and AST) been submitted? 36. Does the patient have pre-existing hepatic disease or hepatic impairment, a history of autoimmune hepatitis, or other autoimmune condition involving the liver? [If no, skip to question 50.] 37. Is the request for Ocrevus? 38. Has the member been screened for hepatitis B and determined not to have an active hepatitis B infection? [If yes, skip to question 50.] 39. Is the request for Aubagio? [If no, skip to question 41.] 40. Have all of the following labs been completed within the last 6 months: A) Complete blood count (CBC), B) Liver function tests (LFTs) and bilirubin levels, and C) Tuberculin skin test 41. Is the request for Gilenya? [If no, skip to question 48.] 42. Have all of the following labs been completed within the last 6 months: A) Complete blood count (CBC), B) Liver function tests (LFTs) and bilirubin Reference umber: C6578 A / Effective Date: 02/01/2018 5

6 levels, C) EKG evaluation, and D) Ophthalmic examination Circle es or o 43. Does the member have a confirmed history of chicken pox OR vaccination for the varicella zoster virus OR lab testing confirming varicella antibodies? 44. Has the member experienced any of the following within the last 6 months: A) myocardial infarction, B) unstable angina, C) stroke, D) TIA (transient ischemic attack), or E) decompensated heart failure requiring hospitalization 45. Does the patient have a QTc interval greater than or equal to 500 msec, a history of Mobitz type II (2nd or 3rd degree AV block) or sick sinus syndrome? 46. Does the patient have Class III or IV heart failure? 47. Is the patient receiving treatment with Class Ia or Class III anti-arrhythmic drugs? [If no, skip to question 51.] 48. Is the request for Tecfidera? 49. Has the member had a complete blood count measured within the past 6 months? 50. Has the member had an inadequate response, intolerable side effects, or has a contraindication to 2 formulary agents, one of which must be a formulary interferon or glatiramer acetate agent? (see formulary for a list of preferred agents) ote: Examples of treatment failure include 2 or more relapses in one year or one severe relapse, MRI lesion progression (i.e., increase in T1, T2, or gadolinium lesions), worsening disability or EDSS score. Reference umber: C6578 A / Effective Date: 02/01/2018 6

7 Circle es or o List medications tried and description of failure: 51. Will all other multiple sclerosis medications (not including Ampyra) be discontinued before starting the requested medication? [If no, then no further questions] 52. Is the member at least 18 years old? 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 Reference umber: C6578 A / Effective Date: 02/01/2018 7