Download Rituxan® (Rituximab) Medication Precertification Request

Rituxan® (Rituximab) Medication
Precertification Request
Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
Page 1 of 2
(All fields must be completed and return both pages for precertification review)
Please indicate:
Start of treatment, start date:
/
/
Continuation of therapy, date of last treatment:
Precertification Requested By:
A. PATIENT INFORMATION
First Name:
Address:
Home Phone:
DOB:
Allergies:
Current Weight:
lbs or
B. INSURANCE INFORMATION
For Medicare Advantage Part B:
FAX:
1-844-268-7263
Phone:
Last Name:
City:
Work Phone:
/
/
Fax:
State:
ZIP:
Cell Phone:
E-mail:
kgs
Height:
inches or
cms
Does patient have other coverage?
Yes
No
Aetna Member ID #:
If yes, provide ID#:
Carrier Name:
Group #:
Insured:
Insured:
Medicare:
Yes
No If yes, provide ID #:
Medicaid:
Yes
No If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name:
Last Name:
(Check one):
M.D.
D.O.
N.P.
Address:
City:
State:
ZIP:
Phone:
Fax:
St Lic #:
NPI #:
DEA #:
UPIN:
Provider E-mail:
Office Contact Name:
Phone:
Specialty (Check one):
Rheumatologist
Other:
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
Place of Administration:
Dispensing Provider/Pharmacy: Patient Selected choice
Physician’s Office
Retail Pharmacy
Self-administered
Physician’s Office
Outpatient Infusion Center
Phone:
Specialty Pharmacy
Mail Order
Center Name:
Other:
Home Infusion Center
Phone:
Name:
Agency Name:
Phone:
Fax:
Administration code(s) (CPT):
TIN:
PIN:
P.A.
E. PRODUCT INFORMATION
Rituxan: Dose:
Directions for Use:
F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other any other where applicable (*).
Primary ICD Code:
Other ICD Code:
G. CLINICAL INFORMATION - Required clinical information must be completed for ALL precertification requests.
Yes
No
Will Rituxan be used in combination with other biologic agents (e.g., Arzerra, Cimzia, Cosentyx, Enbrel, Humira, Kineret, Remicade, etc.)?
Please check ALL that apply:
Acute lymphoid leukemia (induction/consolidation therapy for Philadelphia chromosome negative)
Refractory autoimmune hemolytic anemia
Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides (Wegener granulomatosis, Churg-Strauss syndrome,
microscopic polyangiitis, and pauci-immune glomerulonephritis)
Yes
No Has the patient had an inadequate response to cyclophosphamide?
Yes
No Will Rituxan be given in conjunction with glucocorticoids?
Antibody mediated rejection in heart transplant recipients (prevention of recurrence)
Chronic lymphocytic leukemia
Chronic graft versus host disease (last resort treatment)
Corticosteroid-refractory autoimmune blistering diseases (pemphigus vulgaris, pemphigus folliaceus, bullous pemphigoid, cicatricial pemphigoid,
epidermolysis bullosa acquisita and paraneoplastic pemphigus)
Cryoglobulinemia refractory to corticosteroids and other immunosuppressive agents
Refractory immune or idiopathic thrombocytopenic purpura
Refractory thrombotic thrombocytopenic purpura
Lymphocyte-predominant Hodgkins lymphoma
Multi-centric Castleman's disease (angiofollicular lymph node hyperplasia)
Neuromyelitis optica
Yes
No Has the patient failed one or more immunotherapies? If yes, please provide the name(s) and date range used:
Name(s):____________________________________________ Date ranges:
/
/
/
Non-Hodgkin's lymphoma
Yes
No Has the patient received Rituxan infusions in the past? If yes, please provide the name(s) and date range used:
/
Name(s):____________________________________________ Date range:
/
/
/
/
Yes
No Has the patient received more than 2 courses of infusions (each course may entail 4 to 8 weekly infusions) in 48 weeks?
Post-transplant lymphoproliferative disorder
Prophylaxis of rejection in sensitized kidney transplant recipients with donor specific antibodies
Continued on next page
GR-68535 (9-16)
Rituxan® (Rituximab) Medication
Precertification Request
Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
Page 2 of 2
(All fields must be completed and return both pages for precertification review)
Patient First Name
Patient Last Name
For Medicare Advantage Part B:
FAX:
1-844-268-7263
Patient Phone
Patient DOB
H. CLINICAL INFORMATION Section 2 - Required clinical information must be completed for ALL precertification requests.
Multiple Sclerosis
Please indicate which of the following types of Multiple Sclerosis the patient is diagnosed with:
Relapsing-Remitting MS
Secondary-Progressive MS
Primary-Progressive MS
Progressive-Relapsing MS
Yes
No Has the patient had an inadequate response to medications used to treat Multiple Sclerosis?
Which of the following MS medications has the patient tried and had a documented failure to?
alemtuzumab (Lemtrada) : Please indicate the date range of trial:
/
/
/
/
Please define the failure of therapy*:
Increasing relapses
Lesion progression by MRI
Worsening of Disability
daclizumab (Zinbryta) : Please indicate the date range of trial:
/
/
/
/
Please define the failure of therapy*:
Increasing relapses
Lesion progression by MRI
Worsening of Disability
dalfampridine (Ampyra) : Please indicate the date range of trial:
/
/
/
/
Please define the failure of therapy*:
Increasing relapses
Lesion progression by MRI
Worsening of Disability
dimethyl fumarate (Tecfidera) : Please indicate the date range of trial:
/
/
/
/
Please define the failure of therapy*:
Increasing relapses
Lesion progression by MRI
Worsening of Disability
glatiramir acetate (Copaxone or Glatopa): Please indicate the date range of trial:
Please define the failure of therapy*:
Increasing relapses
Increasing relapses
/
Lesion progression by MRI
fingolimod (Gilenya): Please indicate the date range of trial:
Please define the failure of therapy*:
/
/
/
-
Increasing relapses
Please define the failure of therapy*:
Increasing relapses
/
-
/
/
/
-
/
-
Worsening of Disability
/
___________
Other:
___________
Other:
___________
Other:
___________
Other:
/
___________
/
Other:
___________
Other:
___________
/
Lesion progression by MRI
teriflunomide (Aubagio): Please indicate the date range of trial:
Other:
/
Worsening of Disability
Lesion progression by MRI
/
___________
/
Lesion progression by MRI
natalizumab (Tysabri): Please indicate the date range of trial:
/
Worsening of Disability
/
interferon beta (Avonex, Betaseron, Extavia, Rebif): Please indicate the date range of trial:
Please define the failure of therapy*:
-
Other:
Worsening of Disability
/
/
Please define the failure of therapy*:
Increasing relapses
Lesion progression by MRI
Worsening of Disability
Other:
___________
* Increasing relapses: defined as two or more relapses in a year, or one severe relapse associated with either poor recovery or MRI lesion progression
* Lesion progression by MRI: defined as increased number or volume of gadolinium-enhancing lesions, T2 hyperintense lesions or T1 hypointense lesions
* Worsening disability: defined by sustained worsening of Expanded Disability Status Scale (EDSS) score or neurological examination findings
Relapsed or refractory hairy cell leukemia
Yes
No Has the patient had failure of multiple (2 or more) courses of cladribine?
Please provide the date range of course #1: Date range:
/
/
/
/
Please provide the date range of course #2: Date range:
/
/
/
/
Rheumatoid Arthritis
Yes
No Does the patient have moderate to severe active rheumatoid arthritis?
Yes
No Has the patient had an incomplete response to Remicade? If yes, provide the date range:
/
/
/
/
Yes
No Has the patient had an incomplete response to any of the following: Enbrel, Humira or Simponi Aria?
Yes
No Does the patient have an intolerance or contraindication to 2 of the following: Enbrel, Humira, Remicade, Simponi Aria?
Please describe the intolerance or contraindication:
______________________________________
Please provide the name and date ranges of all medication tried:
Medication:
Dates:
/
/
/
/
Yes
No Will rituximab be used in combination with methotrexate?
Sjogren syndrome
Yes
No Is Sjogren's refractory to corticosteroids and other immunosuppressive agents?
Please provide the names and date range of the corticosteroids and other immunosuppressive used:
Name(s):
_____________________________________________ Date ranges:
/
/
Small lymphocytic lymphoma
Waldenström’s macroglobulinemia
Opsoclonus-myoclonus-ataxia
Yes
No Is the opsoclonus-myoclonus-ataxia associated with neuroblastoma?
Yes
No Is the member refractory to steroids, chemotherapy and intravenous immunoglobulins?
Please provide the name and date ranges of the medications tried: Name(s)_________________________ Date:
/
/
/
/
For Continuation Request:
Yes
No
Has the patient had significant improvement or adequate response after 12 weeks of Rituxan treatment?
I. 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-68535 (9-16)