Download Ixekizumab (Taltz®) and Secukinumab (Cosentyx™)

REVIEW REQUEST FOR
Monoclonal Antibodies to Interleukin-17A
Ixekizumab (Taltz®), Secukinumab (Cosentyx®) and Brodalumab (Siliq™)
Provider Data Collection Tool Based on Medical Policy DRUG.00077
Policy Last Review Date:
03/01/2017
Request Date:
Initial Request
Buy and bill
Policy Effective Date:
/
03/06/2017
Provider Tool Effective Date:
03/06/2017
/
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)
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:
Secukinumab (Cosentyx®)
J3490
J3590
Ixekizumab (Taltz®)
J3490
J3590
Brodalumab (Siliq™)
J3490
J3590
Other:
When did the individual first start this drug?
/
/
Duration:
(Weeks)
(mg/kg)
(mg)
(Other)
Frequency (Days, Wks, Months)
Start Date For This Request:
/
/
The Medical Policy based data collection tool is to facilitate a medical necessity review request for the use of an interleukin17A (IL-17A) monoclonal antibody drug [Ixekizumab (Taltz ® ) or Secukinumab (Cosentyx®)] for treatment of an adult with
active ankylosing spondylitis, moderate to severe plaque psoriasis, or active psoriatic arthritis.
Please check all of the following that apply to the individual.
Section 1 (Required for all requests)
□ Individual does NOT have tuberculosis, invasive fungal infection, other active serious infections, or a history of
recurrent infections
□ Individual has had a tuberculin skin test (TST) or a CDC-recommended equivalent test to evaluate for latent tuberculosis
prior to initiating Secukinumab (Cosentyx®) or Brodalumab (Siliq™) or Ixekizumab (Taltz®)
□ Individual will NOT receive brodalumab or ixekizumab or secukinumab in combination with other immunosuppressive
therapy or phototherapy
REVIEW REQUEST FOR
Monoclonal Antibodies to Interleukin-17A
Provider Data Collection Tool Based on Medical Policy DRUG.00077
Policy Last Review Date:
03/01/2017
Policy Effective Date:
03/06/2017
Provider Tool Effective Date:
03/06/2017
□ Individual will NOT receive brodalumab in combination with a biologic DMARD (such as adalimumab, certolizumab pegol,
etanercept, infliximab, ixekizumab, secukinumab or ustekinumab)
□ Individual will NOT receive ixekizumab in combination with a biologic DMARD (such as adalimumab, brodalumab,
certolizumab pegol, etanercept, infliximab, or ustekinumab)
□ Individual will NOT receive secukinumab in combination with a biologic DMARD (such as adalimumab, brodalumab,
certolizumab pegol, etanercept, infliximab, ixekizumab or ustekinumab)
Section 2: Ankylosing Spondylitis (AS)
□ Request is for the use of Secukinumab (Cosentyx®) in the treatment of an individual 18 years of age or older diagnosed
with active ankylosing spondylitis. (If checked, answer the following that apply to the individual)
□ Cosentyx™ will be used to reduce signs or symptoms
□ Cosentyx™ will be used to induce or maintain clinical response
□ Individual has failed to respond to, is intolerant of, or has a medical contraindication to conventional drug therapy
including a tumor necrosis factor antagonist
Section 3: Moderate to Severe Plaque Psoriasis (Ps)
□ Request is for the use of Brodalumab (Siliq™) in the treatment of an individual 18 years of age or older diagnosed
with moderate to severe plaque psoriasis
□ Request is for the use of Ixekizumab (Taltz®), in the treatment of an individual 18 years of age or older diagnosed
with moderate to severe plaque psoriasis
□ Request is for the use of Secukinumab (Cosentyx®) in the treatment of an individual 18 years of age or older diagnosed
with moderate to severe plaque psoriasis
(If either of the above is checked, answer the following when they apply to the individual)
□ Plaque psoriasis involves greater than 5% BSA
□ Plaque psoriasis involves less than or equal to 5% BSA involving sensitive areas or areas that significantly
impact daily function (such as, palms, soles of feet, head, neck, or genitalia)
□ Agent will be used to reduce signs or symptoms
□ Agent will be used to induce or maintain clinical response
□ Individual has failed to respond to, is intolerant of, or has a medical contraindication to phototherapy or other systemic
therapy (such as acitretin, cyclosporine, or methotrexate)
Section 4: Active Psoriatic Arthritis (PsA)
□ Request is for the use of Secukinumab (Cosentyx®) in the treatment of an individual 18 years of age or older diagnosed
with psoriatic arthritis. (If checked, answer any of the following that apply to the individual)
□ Cosentyx™ will be used to reduce signs or symptoms
□ Cosentyx™ will be used to induce or maintain clinical response
□ Individual has failed to respond to, is intolerant of, or has a medical contraindication to conventional drug therapy
including disease-modifying anti-rheumatic drug or tumor necrosing factor antagonists
Section 5: Other Treatment Indication
□ Request is for other indication(s) not listed above (Please submit all supporting documents including labs, progress
notes, imaging, etc., for review.)
Page 2 of 3
REVIEW REQUEST FOR
Monoclonal Antibodies to Interleukin-17A
Provider Data Collection Tool Based on Medical Policy DRUG.00077
Policy Last Review Date:
03/01/2017
Policy Effective Date:
03/06/2017
Provider Tool Effective Date:
03/06/2017
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
designees 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 3 of 3