Download Individual`s Name: Date of Birth: / / Insurance

REVIEW REQUEST FOR
H.P. Acthar® Gel
Provider Data Collection Tool Based on Clinical Guideline CG-DRUG-24
AIM Specialty Pharmacy Review
(888) 223-0550
Policy Last Review Date: 08/14/2014
Request Date:
Initial Request
Buy and bill
/
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/14/2014
/
Subsequent Request
Individual’s Name:
Date of Birth:
/
/
Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
Diagnosis Code(s) (if known):
Ordering Provider Name & Specialty:
Individual’s Weight
(lbs) (kg)
Individual’s Height
(in)
(cm)
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering Provider):
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Place of Service:
Home
Office
Dialysis Center
Outpatient Hospital
Ambulatory Infusion
Ambulatory Infusion Center
Other:
Drug Name/HCPCS Code (if known)
Dose to be administered:
H.P. Acthar® Gel
J0800 Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
/
/
Duration:
Start Date For This Request:
(Weeks)
/
/
(units/m2)
(other)
Please check all that apply to the individual:
Request is for repository corticotropin (H.P. Acthar® Gel) injection for the treatment of
infantile spasms (West syndrome)
Infant or child is less than two years of age
H.P. Acthar® Gel will be given as monotherapy
Other
Request is for repository corticotropin injection for an adult with a corticosteroid-responsive condition
The individual is diagnosed with acute exacerbations of multiple sclerosis
The individual is diagnosed with another corticosteroid-responsive condition
The individual has no contraindication to or is not limited by contraindications to or intolerance
of glucocorticosteroid effects
There is clear documentation of why all other well-established routes for corticosteroid therapy (for
example, oral prednisone and intravenous methylprednisolone) cannot be used
Please provide specific information that supports the above request:
Other Indications not otherwise specified ( (Please submit all supporting documents including labs, progress
notes, imaging, etc., for review.):
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designee may perform a routine audit and request the medical documentation to verify the accuracy of the information reported
on this form.
/
/
Name & Title of Provider or Provider Representative Completing Form
Date
& attestation (Please Print)*
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management
services on behalf of your health benefit plan or the administrator of your health benefit plan.
Page 2 of 2