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)
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