Individual Plan Tofacitinib (XeljanzTM) Medication Precertification Request Aetna Precertification Notification Phone: 1-800-414-2386 FAX: 1-800-408-2386 (All fields must be completed and legible for Precertification Review) Please indicate: Start of treatment: Start Date / / Continuation of therapy: Date of Last Treatment / Precertification Requested By: / Phone: Fax: A. PATIENT INFORMATION First Name: Last Name: DOB: Address: City: State: Home Phone: Work Phone: Patient Current Weight: lbs or kgs Cell Phone: Patient Height: inches or ZIP: E-mail: cms Allergies: B. INSURANCE INFORMATION Does patient have other coverage? If yes, provide ID#: Insured: Aetna Member ID #: Group #: Insured: Medicare: Yes Medicaid: No If yes, provide ID #: C. PRESCRIBER INFORMATION First Name: Last Name: Address: City: Phone: Fax: No If yes, provide ID #: (Circle one): M.D. D.O. N.P. P.A. State: St Lic #: Provider E-mail: Yes Yes No Carrier Name: NPI #: DEA #: UPIN: Office Contact Name: Specialty (Check one): Rheumatologist ZIP: Phone: Other: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION Place of Administration: Self-administered Physician’s Office Dispensing Provider/Pharmacy: Patient Selected choice Physician’s Office Specialty Pharmacy Other: Retail Pharmacy Mail Order Name: Administration code(s) (CPT): Phone: TIN: E. PRODUCT INFORMATION Request is for: Xeljanz 5 mg Dose: Fax: PIN: Frequency: F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other any other where applicable (*). Primary ICD Code: 714.0 Rheumatoid Arthritis 714.2 Other Rheumatoid Arthritis with visceral or systemic involvement Secondary ICD Code: Other: G. CLINICAL INFORMATION - Required clinical information must be completed for ALL precertification requests. Yes Yes Yes No Is the patient an adult with moderately to severely active rheumatoid arthritis? No Has the patient had an inadequate response or intolerance to methotrexate? No Does the patient have a documented recent tuberculin skin test (within 6 months) to check for latent tuberculosis? If yes: Date of TB test: / / Yes No Does the patient have a contraindication, intolerance or incomplete response to any of the following? If yes, check ALL that apply: Enbrel Humira Remicade Yes No Will the patient use tofacitinib (Xeljanz) in combination with a biologic disease-modifying anti-rheumatic drug (DMARD)? Yes No Will the patient use tofacitinib (Xeljanz) in combination with azathioprine, cyclosporine or other potent immunosuppressant? H. 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. The plan may request additional information or clarification, if needed, to evaluate requests. GR-68856-1 (12-14)