Individual Plan Vedolizumab (Entyvio) Medication

Individual Plan Vedolizumab (Entyvio®)
Injectable Medication Precertification Request
Aetna Precertification Notification
Phone: 1-800-414-2386
FAX:
1-800-408-2386
(Please complete all fields and return both pages for precertification review)
Please indicate:
Start of treatment: Start Date:
/
/
Continuation of therapy: Date of last treatment:
Precertification Requested By:
A. PATIENT INFORMATION
Phone:
Last Name:
DOB:
Address:
City:
State:
Work Phone:
Current Weight:
lbs or
kgs
Cell Phone:
Height:
inches or
cms
/
Fax:
First Name:
Home Phone:
/
ZIP:
E-mail:
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 #:
Yes
Yes
No
Carrier Name:
No If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name:
Last Name:
Address:
City:
Phone:
Fax:
Check One:
NPI #:
Place of Administration:
Self-administered
Outpatient Infusion Center
Center Name:
Home Infusion Center
Agency Name:
N.P.
P.A.
ZIP:
DEA #:
Office Contact Name:
Specialty (Check one):
Rheumatologist
Dermatologist
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
D.O.
State:
St Lic #:
Provider E-mail:
M.D.
UPIN:
Phone:
Gastroenterologist
Other:
Dispensing Provider/Pharmacy: (Patient selected choice)
Physician’s Office
Retail Pharmacy
Specialty Pharmacy
Mail Order
Other:
Name:
Physician’s Office
Phone:
Phone:
Administration code(s) (CPT):
Phone:
Fax:
TIN:
PIN:
E. PRODUCT INFORMATION
Request is for Entyvio:
Dose:
Frequency:
F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other where applicable.
Primary ICD Code:
Ulcerative colitis (556 - 556.9)
Secondary ICD Code:
Other:
G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests.
For Ulcerative Colitis
Yes
No
Is the patient hospitalized with fulminant ulcerative colitis?
Yes
No
Does the patient have moderately to severely active ulcerative colitis?
Yes
No
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?
Yes
No
Is the patient refractory to or have a contraindication to 5-aminosalicylic acid agents (e.g., balsalazide, mesalamine, sulfasalazine)?
Yes
No
Is the patient refractory to or have a contraindication to immunosuppressants (e.g., 6-mercaptopurine or azathioprine)?
Yes
No
Does the patient have a contraindication, intolerance, or an incomplete response to Humira and Remicade?
For Crohn’s Disease
Yes
No
Does the patient have active Crohn’s disease manifested by:
Check all that apply:
abdominal pain
arthritis
bleeding
intestinal obstruction
megacolon
perianal disease
Yes
Yes
No
No
diarrhea
spondylitis
internal fistulae
weight loss
Has the Crohn’s disease remained active despite treatment with 6-mercaptopurine, azathioprine or corticosteroids?
Does the patient have a contraindication, intolerance, or an incomplete response to Humira and Remicade?
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-69012-1 (12-14)