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)