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REVIEW REQUEST FOR H.P. Acthar® Gel Provider Data Collection Tool Based on Clinical Guideline CG-DRUG-24 AIM Specialty Pharmacy Review (888) 223-0550 Policy Last Review Date: 08/14/2014 Request Date: Initial Request Buy and bill / Policy Effective Date: 10/14/2014 Provider Tool Effective Date: 10/14/2014 / 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) Individual’s Height (in) (cm) 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: H.P. Acthar® Gel J0800 Other: When did the individual first start this drug? Frequency (Days, Wks, Months) / / Duration: Start Date For This Request: (Weeks) / / (units/m2) (other) Please check all that apply to the individual: Request is for repository corticotropin (H.P. Acthar® Gel) injection for the treatment of infantile spasms (West syndrome) Infant or child is less than two years of age H.P. Acthar® Gel will be given as monotherapy Other Request is for repository corticotropin injection for an adult with a corticosteroid-responsive condition The individual is diagnosed with acute exacerbations of multiple sclerosis The individual is diagnosed with another corticosteroid-responsive condition The individual has no contraindication to or is not limited by contraindications to or intolerance of glucocorticosteroid effects There is clear documentation of why all other well-established routes for corticosteroid therapy (for example, oral prednisone and intravenous methylprednisolone) cannot be used Please provide specific information that supports the above request: Other Indications not otherwise specified ( (Please submit all supporting documents including labs, progress notes, imaging, etc., for review.): 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 designee 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 2 of 2