Download Hereditary Angioedema Medication Precertification Request

Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
Hereditary Angioedema Injectable
Medication Precertification Request
Page 1 of 2
(All fields must be completed and legible for Precertification Review.)
Please indicate:
Start of treatment: Start date
/
/
Continuation of therapy: Date of last treatment
/
For Medicare Advantage Part B:
FAX:
1-844-268-7263
/
Precertification Requested By:
Phone:
Fax:
A. PATIENT INFORMATION
First Name:
Last Name:
Address:
City:
Home Phone:
State:
Work Phone:
DOB:
Allergies:
Current Weight:
ZIP:
Cell Phone:
Email:
lbs or
kgs
Height:
inches or
cms
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
First Name:
Last Name:
Address:
City:
Phone:
Fax:
(Check One):
NPI #:
Allergist
Immunologist
N.P.
P.A.
ZIP:
DEA #:
Office Contact Name:
Specialty (Check one):
D.O.
State:
St Lic #:
Provider Email:
M.D.
UPIN:
Phone:
Other:
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):
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:
Dose:
Berinert
Cinryze
Firazyr
Kalbitor
Ruconest
Frequency:
F. DIAGNOSIS INFORMATION – Please indicate primary ICD Code and specify any other where applicable.
Primary ICD Code:
Secondary ICD Code:
Other ICD Code:
G. CLINICAL INFORMATION – Required clinical information must be completed in its entirety for all precertification requests.
For All Requests – Please submit a copy of the Laboratory reports and clinicals with request
What is the patient’s C4 level and date drawn:
Date:
/
/
What is the patient’s C1 inhibitor (C1INH) antigenic level and date drawn:
Date:
/
/
What is the patient’s C1 inhibitor (C1INH) functional level and date drawn:
Date:
/
/
Please indicate which of the following pertains to the patient
Low C1INH antigenic level (less than 19 mg/ dL; or below the lower limit of normal as defined by the laboratory performing the test)
Normal C1INH antigenic level (formerly type III HAE)
Normal C1INH antigenic level (greater than or equal to 19 mg/ dL) AND a low C1INH function level (functional level less than 50%; or below
the lower limit of normal as defined by the laboratory performing the test)
None of the above
Yes
No Does the patient have a diagnosis of hereditary angioedema (HAE) based on documented evidence of a low C4 level or below the
lower limit of normal?
If yes,
Yes
No Will the medication be used for treatment of acute attacks associated with HAE?
Yes
No Does the patient have clinical evidence of attacks associated with hereditary angioedema with a normal C1INH deficiency (formerly
type III HAE)?
If yes,
Yes
No Does the patient have a documented history of recurrent angioedema in the absence of concomitant hives or
concomitant use of a medication known to cause angioedema?
Yes
No Is there documentation of a F12 mutation that is associated with the disease?
Yes
No Does the patient have a positive family history of angioedema?
Continued on next page
GR-68676 (6-16)
Hereditary Angioedema Injectable
Medication Precertification Request
Page 2 of 2
(All fields must be completed and legible for Precertification Review.)
Patient First Name
Patient Last Name
Patient Phone
Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
For Medicare Advantage Part B:
FAX:
1-844-268-7263
Patient DOB
G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests.
Yes
Yes
Yes
Yes
No Does the patient have documented evidence of a lack of efficacy of chronic high-dose antihistamine therapy (e.g.
cetirizine 40 mg/ day or equivalent)?
If yes, please indicate the antihistamine and dosage that the patient has tried:
Dose:
How long was the trial of the antihistamine?
Less than 1 month
More than 1 month
Yes
No Were there at least 3 attacks of angioedema expected to occur during the antihistamine therapy?
No Have medications known to cause angioedema been evaluated and discontinued when appropriate?
If yes, please select which type of medication(s) have been discontinued:
Ace inhibitors
Estrogens
Angiotensin II receptor blockers
Other:
No Is the patient experiencing any symptoms of moderate to severe attack?
If yes, please select the following symptom(s) the patient has experienced:
Airway swelling
Severe abdominal pain
Facial swelling
Nausea and vomiting
Painful facial distortion
Other:
No Will the medication be used in combination with any other medication used to treat HAE?
If yes, please choose the combination of HAE medications that will be given:
Firazyr
Kalbitor
Ruconest
Berinert
For Firazyr only
Yes
No Will Firazyr be used for treatment of acute attacks of angioedema from angiotensin converting enzyme (ACE) inhibitors?
If yes, please identify which ACE inhibitor taken:
For Cinryze only
Please indicate the number of HAE attacks per month the patient is experiencing:
Yes
No Will Cinryze be used as prophylaxis against angioedema attacks?
Yes
No Is the patient currently experiencing any signs of acute angioedema?
Yes
No Does the patient have a documented HAE-causing C1INH mutation?
Yes
No Has the patient tried and failed a 17 alpha-alkylated androgen?
If yes, please provide the name(s) and dates the medication was tried:
Dates:
/
/
to
/
/
Dates:
/
/
to
/
/
Dates:
/
/
to
/
/
Yes
No Does the patient have an intolerance or contraindication to 17 alpha-alkylated androgens?
If yes, please describe the intolerance or contraindication:
Yes
No Has the patient tried and failed anti-fibrinolytic agents for HAE prophylaxis?
If yes, please provide the name(s) and dates the medication was tried:
Dates:
/
/
to
/
/
Dates:
/
/
to
/
/
Dates:
/
/
to
/
/
Yes
No Does the patient have an intolerance or contraindication to anti-fibrinolytic agents for HAE prophylaxis?
If yes, please describe the intolerance or contraindication:
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-68676 (6-16)