Infliximab (Remicade®) Injectable Medication Precertification Request Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 Page 1 of 2 (Please complete all fields and return both pages for precertification review) Please indicate: Start of treatment: Start date Precertification Requested By: A. PATIENT INFORMATION First Name: Address: Home Phone: Current Weight: lbs or B. INSURANCE INFORMATION / Yes Continuation of therapy: Date of last treatment Phone: Work Phone: kgs Height: Does patient have other coverage? If yes, provide ID#: Insured: No If yes, provide ID #: Medicaid: C. PRESCRIBER INFORMATION First Name: Address: Phone: Fax: Provider Email: Specialty (Check one): Dermatologist Last Name: City: St Lic #: Office Contact Name: Gastroenterologist D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION Place of Administration: Self-administered Physican’s Office Outpatient Infusion Center Phone: Center Name: Home Infusion Center Phone: Agency Name: Administration code(s) (CPT): DOB: State: Email: Cell Phone: cms Allergies: inches or / ZIP: Yes No Carrier Name: Yes No If yes, provide ID #: (Circle one): M.D. D.O. N.P. P.A. State: ZIP: DEA #: UPIN: Phone: NPI #: Rheumatologist / Fax: Last Name: City: Aetna Member ID #: Group #: Insured: Medicare: / Other: Dispensing Provider/Pharmacy: (Patient selected choice) Physician’s Office Retail Pharmacy Specialty Pharmacy Mail Order Other: Name: Phone: TIN: Fax: PIN: E. PRODUCT INFORMATION Request is for Remicade: Dose: Frequency: F. DIAGNOSIS INFORMATION - Please indicate primary ICD-9 code and specify any other where applicable. Primary ICD-9: Other: G. CLINICAL INFORMATION - Required clinical information must be completed completed in its entirety for all precertification requests. Crohn’s Disease Yes No Does the patient have active Crohn’s disease manifested by: abdominal pain arthritis bleeding diarrhea internal fistulae intestinal obstruction If yes, check all that apply: megacolon perianal disease spondylitis weight loss Yes No Has the Crohn’s disease remained active despite treatment with 6-mercaptopurine, azathioprine or corticosteroids? Yes No Does the patient have fistulizing Crohn’s disease? Yes No Has the fistulizing Crohn’s disease been active for at least 3 months? Ulcerative Colitis Yes Yes Yes No No No Yes Yes No No Is the patient hospitalized with fulminant ulcerative colitis? Does the patient have moderately to severely active ulcerative colitis? Is the patient refractory to or require continuous immunosuppression with corticosteroids (e.g., methylprednisolone, prednisone) at a dose of prednisone 40 to 60 mg/day (or equivalent) for 30 days for oral therapy or 7 to 10 days for IV therapy? Is the patient refractory to or have a contraindication to 5-aminosalicylic acid agents (e.g., balsalazide, mesalamine, sulfasalazine)? Is the patient refractory to or have a contraindication to immunosuppressants (e.g., 6-mercaptopurine or azathioprine)? Psoriasis Yes Yes Yes Yes Yes Yes No No No No No No Does the patient have moderate to severe chronic plaque psoriasis? Is the patient a candidate for systemic therapy or phototherapy? Does the plaque psoriasis affect 10% or more of the body surface area? Does the plaque psoriasis affect 5% or more of the body surface area involving sensitive areas such as the hands, feet, face, or genitals? Does the patient have a Psoriasis Area and Severity Index (PASI) score of 10 or more? In correspondence to the current psoriasis flare or treatment request has the patient failed to adequately respond to or was the patient intolerant to a 3-month trial of one of the following phototherapies listed below? If yes, check all that apply: Psoralens (methoxsalen, trioxsalen) with UVA light (PUVA) UVB with coal tar or dithranol UVB (standard or narrow-band) Contraindicated: Please explain: FOR CONTINUATION OF THERAPY: Yes No Has the patient failed to adequately respond to 12 weeks of infliximab (Remicade) treatment? GR-68855 (10-13) Infliximab (Remicade®) Injectable Medication Precertification Request Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 Page 2 of 2 (Please complete all fields and return both pages for precertification review) Patient First Name Patient Last Name Patient Phone Patient DOB H. CLINICAL INFORMATION Section 2 - Required clinical information must be completed in its entirety for allprecertification requests. Psoriatic Arthritis Yes No Does the patient have moderately to severely active psoriatic arthritis? Yes No Has the patient had an inadequate response to non-biologic disease-modifying anti-rheumatic drugs (DMARDs)? azathioprine cyclosporine leflunomide methotrexate sulfasalazine Other: If yes, check ALL that apply: Rheumatoid Arthritis Yes No Does the patient have moderately to severely active rheumatoid arthritis? Yes No Will the patient be using infliximab (Remicade) in combination with methotrexate? If no, please explain why: Juvenile Idiopathic Arthritis Yes No Does the patient have moderately to severely active polyarticular juvenile idiopathic arthritis? Yes No Does the patient have a contraindication, intolerance, or incomplete response to etanercept (Enbrel) AND adalimumab (Humira)? Reactive Arthritis or Inflammatory Bowel Disease Arthritis Yes No Does the patient have refractory reactive arthritis or inflammatory bowel disease arthritis (enteropathic arthritis)? Yes No Has the patient failed or been intolerant to methotrexate? Yes No Has the patient failed or been intolerant to sulfasalazine? Yes No Has the patient failed or been intolerant to non-steroidal anti-inflammatory drugs (NSAIDs)? Spondylitis Yes No Does the patient have active ankylosing spondylitis or other active spondyloarthropathy with evidence of inflammatory disease? Yes No Has the patient had an inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs)? celecoxib diclofenac ibuprofen indomethacin meloxicam naproxen sulindac If yes, check ALL that apply: Other Chronic Pulmonary Sarcoidosis Yes No Does the patient remain symptomatic despite treatment for 3 or more months with both steroids AND immunosuppressants? Yes No Was the steroid dose 10mg per day or more? Pyoderma Gangrenosum Yes No Does the patient have refractory pyoderma gangrenosum? Uveitis Yes No Does the patient have refractory Bechet’s uveitis? Hidradinitis suppurativa Yes No Does the patient have severe disease refractory to systemic antibiotics? I. ACKNOWLEDGEMENT Request Completed By (Signature Required): Date: / / Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. GR-68855 (10-13)