Download Provider Bulletin: [Subject]

Anthem Blue Cross and Blue Shield
State Sponsored Business
Remicade® (infliximab) Enrollment Form
Fax completed form to: PrecisionRx Specialty Solutions
Fax number: 1-866-862-3170 | Provider Services phone number: 1-888-662-0944
Part I Patient Information
Patient’s last name
First name
Middle initial
Address
City
Day phone number
(
)
Parent/Guardian
State
Night phone number
(
)
Allergies
Date of birth
/
Primary insurance
Secondary insurance
Cardholder name (if not patient)
Cardholder name (if not patient)
Member ID and Group number
BIN#
Insurance phone number (+area code)
(
)
Employer
ZIP code
/
Sex
M
Member ID and Group number
F
BIN#
Insurance phone number (+area code)
(
)
Employer
Part II Physician Information (please supply copy of patient’s insurance card)
Prescriber’s name
Hospital/Clinic
Office contact name
Address
City
Phone number (+area code)
(
)
DEA number
State
Fax number (+area code)
(
)
NPI
ZIP code
UPIN
Part III Medical Criteria (double click on the fields below to fill in this form electronically)
MEDICAL CRITERIA
Primary Diagnosis (ICD9 Code):
Secondary Diagnosis (ICD9 Code):
Prior Therapy:
Yes
No Has patient received previous treatment? If yes, drug(s) used and dates of therapy:
Drug:
Date:
/
/
Duration:
Drug:
Date:
/
/
Duration:
Approval Criteria for Remicade:
Patient has none of the following concomitant conditions:
Yes
No Patient has hypersensitivity to any murine proteins or other components of the product
Yes
No Patient has moderate to severe (NYHA Class III/IV) Congestive Heart Failure (CHF)
Yes
No Individuals with CHF who develop new symptoms or worsening symptoms of pre-existing CHF
Yes
No Patient has Tuberculosis or other active infection
Yes
No Patients has had a tuberculin skin test to rule out latent tuberculosis.
Yes
No Patient has Multiple Sclerosis and other demyelinating diseases
Yes
No Remicade will be used in combination with other tumor necrosis factor blocking agents or anakinra (Kineret)
Yes
No Patient is currently receiving phototherapy, systemic psoriasis therapy (except for methotrexate, glucocorticoids, salicylates, nonsteroidal anti-inflammatory drugs, or analgesics), immunosuppressive therapy, or Anakinra.
Yes
No Patient is a pregnant women or nursing mother
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered
trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. PrecisionRx
Specialty Solutions is a pharmacy and department of NextRx, LLC.
0609 INW2402 06/05/09
State Sponsored Business, Anthem Blue Cross and Blue Shield
Remicade® (infliximab) Enrollment Form
Page 2 of 4
Patient’s Last Name:
First Name:
DOB:
/
/
Part III Medical Criteria (continued)
Rheumatoid Arthritis (RA):
Yes
No Patient has a diagnosis of moderately to severely active Rheu`matoid Arthritis
Yes
No Patient is 18 years of age or older
Yes
No Patient is currently on methotrexate (if patient is intolerant to methotrexate, in combination with another immunosuppressive
agent that has also been demonstrated to prevent the development of human anti-chimeric antibodies [HACA], i.e.
azathioprine, cyclosporine, or sulfasalazine)
Yes
No Patient has had an inadequate response to one or more DMARDs (disease-modifying antirheumatic drugs such as
azathioprine, gold, hydroxychloroquine, leflunomide, methotrexate, and sulfasalazine)
Crohn’s Disease (CD):
Yes
No Patient has diagnosis of moderately to severely active Crohn’s Disease (adult and pediatric greater than or equal to 6 (six)
years of age) manifested by one or more of following symptoms: Check boxes that apply:
Abdominal pain
Bleeding
Diarrhea
Extraintestinal manifestations (arthritis, uveitis, iritis, pyoderma gangrenosum, erythema nodosum, or spondylitis) internal
fistulae
Intestinal obstruction
Perianal disease
Megacolon
Weight loss
Yes
No Patient had an inadequate response to conventional therapy [oral mesalamine, oral corticosteroids, and 6-mercaptopurine or
azathioprine (6-MP/AZA)]
Yes
No Patient has fistulizing Crohn’s disease with draining enterocutaneous or rectovaginal fistulas, of at least 3 months duration
Yes
No Patient has fistulizing or moderate to severely active Crohn’s disease who have responded to previous therapy with Remicade
Ulcerative Colitis:
Yes
No Patient is 18 years of age or older
Yes
No Patient has diagnosis of moderately to severely active Ulcerative Colitis
Yes
No Patient has had an inadequate response to conventional therapy
Active ankylosing spondylitis (AS) (adult):
Yes
No Patient is 18 years of age or older
Yes
No Patient has diagnosis of active ankylosing spondylitis
Yes
No Patient has failed, had an inadequate response to or is not indicated for treatment with sulfasalazine, methotrexate, or nonsteroidal anti-inflammatory drugs
Active psoriatic arthritis (PsA) (adult):
Yes
No
Patient is 18 years of age or older
Yes
No Patient is diagnosed with Psoriatic Arthritis
Yes
No Patient has active arthritis with at least 5 swollen joints and 5 tender joints
Yes
No Patient has presence of plaque psoriasis with a qualifying target lesion at least 2 cm in diameter
Yes
No Patient has failure or contraindicated for DMARD therapy, specifically methotrexate or sulfasalazine
Patient has arthritis in any of the following distributions:
Yes
No Distal interphalangeal joint involvement
Yes
No Polyarticular arthritis, without rheumatoid nodules
Yes
No Arthritis mutilans
Yes
No Asymmetric arthritis
Yes
No Ankylosing spondylitis-like arthritis
State Sponsored Business, Anthem Blue Cross and Blue Shield
Remicade® (infliximab) Enrollment Form
Page 3 of 4
Patient’s Last Name:
First Name:
DOB:
/
/
MEDICAL CRITERIA (continued)
Chronic Plaque Psoriasis (Ps):
Yes
No Disease is controlled with topical therapy
Yes
No Patient has had a failure of phototherapy or other systemic therapies to achieve an adequate clinical response, or a medical
contraindication to the use of phototherapy (e.g. methotrexate, acetretin, or cyclosporine)
Yes
No Other systemic therapies are medically less appropriate or contraindicated
Yes
No Patient has a diagnosis of moderate to severe Plaque Psoriasis
Yes
No
Patient has greater than 10% of body surface area with plaque psoriasis
Yes
No
Patient has less than or equal to 10% body surface area affected with plaque psoriasis involving
sensitive areas that would significantly impact daily function (such as palms, soles of feet, head/neck,
or genitalia)
Yes
No Patient has diagnosis of reactive arthritis (adult) OR arthritis associated with inflammatory bowel disease
Yes
No No Patient is 18 years of age or older
Juvenile Idiopathic Arthritis:
Yes
No Is the patient diagnosed with moderately to severely active polyarticular juvenile idiopathic arthritis?
Yes
No Has the patient been treated with one or more DMARDs and failed to achieve an adequate clinical response?
Please provide prior therapy(ies) tried:
Date last Taken
/
/
/
/
/
/
Dosing Guidelines
Patient Weight:
lb
/ kg
Rheumatoid Arthritis (RA) (adult):
3mg/kg IV in combination with methotrexate at 0, 2, and 6 weeks then every 8 weeks thereafter
For patients with an incomplete response, the dose may be increased up to 10mg/kg every 4 weeks.
Crohn’s Disease or Fistulizing Crohn’s Disease (CD):
In patients 18 years of age and older:
5mg/kg IV at 0, 2, and 6 weeks then every 8 weeks thereafter
If the individual responds and then loses response consideration may be given to increase to 10mg/kg IV or increase the frequency of
administration from every 8 weeks thereafter to every 6 weeks thereafter.**
**Please note that for these conditions, the administration of Remicade® at every 6 weeks is more frequent than the FDA label indication of every 8
weeks.
In pediatric patients:
5mg/kg IV at 0, 2, and 6 weeks then every 8 weeks thereafter
Ulcerative Colitis (adult):
5mg/kg IV at week 0, 2, and 6 weeks then every 8 weeks thereafter
Active ankylosing spondylitis (AS) (adult):
5mg/kg IV at 0, 2, and 6 weeks then every 6 weeks thereafter
Active psoriatic arthritis (PsA) (adult):
5mg/kg IV at 0, 2, and 6 weeks then every 8 weeks thereafter
Methotrexate may be continued during treatment if desired
Chronic Plaque Psoriasis (Ps) (adult):
5mg/kg IV at week 0, 2, and 6 weeks then every 8 weeks thereafter
State Sponsored Business, Anthem Blue Cross and Blue Shield
Remicade® (infliximab) Enrollment Form
Page 4 of 4
Patient’s Last Name:
PRESCRIPTION
Loading Dose:
First Name:
DOB:
/
/
Remicade® (infliximab)
100mg/20ml
Directions:
Qty / 30 days:
Maintenance Dose:
No Refills
Remicade®
(infliximab)
100mg/20ml
Directions:
Qty / 30 days:
Supplies:
No Refills
Yes
No
Quantity
IV Start Kit (1 kit per infusion
IV Set 84” with 0.22 micron filter (1 set per infusion)
BD Insyte Autoguard Catheter (1 per infusion)
Sodium Chloride 0.9% 250cc bag (1 bag per infusion)
Sterile Water for Injection 10ml (1 vial per vial of Remicade)
BD 10cc 20G 1” syringes (1 syringe per vial of Remicade)
BD 10cc LL syringe OR
BD 30cc LL syringe OR
BD 60cc LL syringe
* Size based on number of Remicade vials per infusion multiplied by 10ml (i.e. 5 vials per infusion would require syringe large enough to draw up
50cc).
BD 22G 1” needle (1 needle per needle free syringe above)
Prescriber’s signature
Date
/
/
PrecisionRx Specialty Solutions is able to fill your request as written. Please provide the following information to expedite your order:
PrecisionRx Specialty Solutions to dispense (check box)
Ship medication to:
Physician Office
Other
Need by Date: :
/
/
*Confidentiality notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above.
The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action
taken in reliance on the contents of this document is strictly prohibited.