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 1-855-799-2551. Please contact Aetna Better Health of Michigan at 1-866-316-3784 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.]
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 46. 10. 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?
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?
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.]
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?
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