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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)