Secukinumab (Cosentyx®) Injectable Medication Precertification Request Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 (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 Cell Phone: kgs Patient Height: inches or ZIP: E-mail: cms Allergies: B. INSURANCE INFORMATION Aetna Member ID #: Group #: Insured: Medicare: Yes Does patient have other coverage? If yes, provide ID#: Insured: No If yes, provide ID #: Medicaid: Yes Yes No Carrier Name: No If yes, provide ID #: C. PRESCRIBER INFORMATION Last Name: First Name: Address: Check One: City: Phone: Fax: Specialty (Check one): NPI #: Rheumatologist P.A. UPIN: Phone: Immunologist 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: Administration code(s) (CPT): N.P. ZIP: DEA #: Office Contact Name: Dermatologist D.O. State: St Lic #: Provider E-mail: M.D. Other: Dispensing Provider/Pharmacy: Patient Selected choice Physician’s Office Retail Pharmacy Specialty Pharmacy Mail Order Other: Name: Phone: Fax: TIN: PIN: E. PRODUCT INFORMATION Request is for Cosentyx: Dose: Frequency: F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other where applicable. Other: Primary ICD Code: 696.1 Other psoriasis G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests. Yes Yes Yes Yes Yes No No No No No Does the patient have moderate to severe chronic plaque psoriasis? Will Cosentyx be used in combination with any other biologic? Is the patient a candidate for systemic therapy or phototherapy? Does the plaque psoriasis affect 10% or more of the body surface area? Does the plaque psoriasis affect 5% or more of the body surface area involving sensitive areas such as the hands, feet, face, or genitals? Yes No Does the patient have a Psoriasis Area and Severity Index (PASI) score of 10 or more? Yes No Has the patient failed to adequately respond to or was the patient intolerant to a 3-month trial to one of the phototherapies listed below? If yes, check all that apply: Psoralens (methoxsalen, trioxsalen) with UVA light (PUVA) UVB with coal tar or dithranol UVB (standard or narrow-band) Yes No Is the phototherapy contraindicated? If yes, Please explain: Yes No Does the patient have a contraindication, intolerance or incomplete response to at least 2 of the following: If yes, check ALL that apply: Enbrel Humira Remicade Stelara For continuation of therapy only… Yes No Has the patient had significant improvement or adequate response after 12 weeks of secukinumab (Cosentyx) treatment? 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-69080 (3-15)