Individual Plan
Multiple Sclerosis Medication
Precertification Request
Aetna Precertification Notification
Phone: 1-800-414-2386
FAX:
1-800-408-2386
Page 1 of 2
(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:
A. PATIENT INFORMATION
First Name:
Address:
Home Phone:
DOB:
Allergies:
Current Weight:
lbs or
B. INSURANCE INFORMATION
Aetna Member ID #:
Group #:
Insured:
Fax:
Last Name:
City:
Work Phone:
State:
ZIP:
Cell Phone:
E-mail:
kgs
Medicare:
Yes
No If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name:
Address:
Phone:
Fax:
Provider E-mail:
Specialty (Check one):
/
Neurologist
Height:
inches or
Does patient have other coverage?
If yes, provide ID#:
Insured:
Medicaid:
Last Name:
City:
St Lic #:
NPI #:
Office Contact Name:
Primary Care
Yes
cms
Yes
No
Carrier Name:
No If yes, provide ID #:
(Check one):
M.D.
D.O.
State:
ZIP:
DEA #:
UPIN:
Phone:
N.P.
P.A.
Other:
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
Place of Administration:
Self-administered
Physician’s Office
Outpatient Infusion Center
Phone:
Center Name:
Home Infusion Center
Phone:
Agency Name:
Dispensing Provider/Pharmacy: (Patient selected choice)
Physician’s Office
Retail Pharmacy
Specialty Pharmacy
Mail Order
Other:
Name:
Phone:
Fax:
TIN:
PIN:
Administration code(s) (CPT):
E. PRODUCT INFORMATION
Request is for:
Aubagio
Avonex
Betaseron
Copaxone
Extavia
Gilenya
Rebif
Tecfidera Dose:
Frequency:
(Failure to indicate dose and frequency may extend review time)
F. DIAGNOSIS INFORMATION – Please indicate primary ICD code and specify any other where applicable.
Primary ICD Code: (340) Multiple Sclerosis
Secondary ICD Code:
Other ICD Code:
G. CLINICAL INFORMATION – Required clinical information must be completed in its entirety for all precertification requests.
ALL DRUGS:
Yes
No
Yes
No
Does the patient have a documented diagnosis of relapsing remitting multiple sclerosis?
Has the patient experienced signs and symptoms of Clinically Isolated Syndrome suggestive of MS that has been confirmed
with magnetic resonance imaging (MRI)?
Yes
No Will the drug requested be used as monotherapy?
Yes
No Has the patient previously tried any of the following medications?
If yes, please check all that apply:
Aubagio
Avonex
Betaseron
Copaxone
Extavia
Gilenya
Plegridy
Rebif
Tecfidera
Tysabri
For AUBAGIO, AVONEX, BETASERON, EXTAVIA, GILENYA, & TECFIDERA - also complete the following:
Yes
No Does the patient have a contraindication, intolerance or allergy to Copaxone?
Yes
No Does the patient have a documented failure of an adequate trial of Copaxone?
If yes, please indicate which of the following describe the evidence of treatment failure:
The patient has increasing relapses (defined as two or more relapses in a year, or one severe relapse associated with either poor
recovery or MRI lesion progression)
The patient has lesion progression by MRI (increased number or volume of gadolinium-enhancing lesions, T2 hyperintense
lesions or T1 hypointense lesions)
The patient has worsening disability (sustained worsening of Expanded Disability Status Scale (EDSS) score or neurological
examination findings).
GR-68750-1 (12-14)
Individual Plan
Multiple Sclerosis Medication
Precertification Request
Aetna Precertification Notification
Phone: 1-800-414-2386
FAX:
1-800-408-2386
Page 2 of 2
(All fields must be completed and legible for precertification review)
Patient First Name
Patient Last Name
Patient Phone
Patient DOB
G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests.
Yes
Yes
No Does the patient have a contraindication, intolerance or allergy to Rebif?
No Does the patient have a documented failure of an adequate trial of Rebif?
If yes, please indicate which of the following describe the evidence of treatment failure:
The patient has increasing relapses (defined as two or more relapses in a year, or one severe relapse associated with either poor
recovery or MRI lesion progression)
The patient has lesion progression by MRI (increased number or volume of gadolinium-enhancing lesions, T2 hyperintense
lesions or T1 hypointense lesions)
The patient has worsening disability (sustained worsening of Expanded Disability Status Scale (EDSS) score or neurological
examination findings).
For AUBAGIO - also complete the following:
Yes
No Does the patient have a documented recent (within 6 months) complete blood count (CBC)?
Yes
No Does the patient have a documented recent (within 6 months) liver transaminase and bilirubin?
Yes
No Does the patient have a documented recent (within 6 months) Tuberculin skin test to check latent Tuberculosis?
Yes
No Has/will the patient’s blood pressure be monitored at initiation and during treatment?
Yes
No If female, does the patient have a documented negative pregnancy test?
Yes
No If female, is there confirmation that reliable contraception will be used during treatment with Aubagio?
For GILENYA - also complete the following:
Yes
No Does the patient have a documented recent (within 6 months) complete blood count (CBC)?
Yes
No Does the patient have a documented recent (within 6 months) liver transaminase and bilirubin?
Yes
No Will the patient have an EKG prior to the first dose and at the end of the observation period?
Yes
No Has the patient had a recent (within the last 6 months) occurrence of myocardial infarction, unstable angina, stroke,
transient ischemic attack, decompensated heart failure requiring hospitalization, or Class III/IV heart failure?
Yes
No Does the patient have history or presence of Mobitz Type II 2nd degree or 3rd degree AV block or sick sinus syndrome?
Yes
No Does the patient have a pacemaker?
Yes
No Does the patient have a baseline QTc interval ≥500 ms (as measured on most recent EKG)?
Yes
No Is the patient on any Class Ia or Class III anti-arrhythmic drugs?
Yes
No Does the patient have a documented baseline ophthalmologic examination?
Yes
No Does the patient have a documented history of chicken pox or administration of the varicella zoster vaccine (VZV)?
Yes
No If female, does the patient have a documented negative pregnancy test?
For TECFIDERA - also complete the following:
Yes
No Does the patient have a documented recent (within 6 months) complete blood count (CBC)?
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-68750-1 (12-14)