Download Individual Plan Tofacitinib (Xeljanz) Medication

Individual Plan Tofacitinib (XeljanzTM)
Medication Precertification Request
Aetna Precertification Notification
Phone: 1-800-414-2386
FAX:
1-800-408-2386
(All fields must be completed and legible for Precertification Review)
Please indicate:
Start of treatment: Start Date
/
/
Continuation of therapy: Date of Last Treatment
/
Precertification Requested By:
/
Phone:
Fax:
A. PATIENT INFORMATION
First Name:
Last Name:
DOB:
Address:
City:
State:
Home Phone:
Work Phone:
Patient Current Weight:
lbs or
kgs
Cell Phone:
Patient Height:
inches or
ZIP:
E-mail:
cms
Allergies:
B. INSURANCE INFORMATION
Does patient have other coverage?
If yes, provide ID#:
Insured:
Aetna Member ID #:
Group #:
Insured:
Medicare:
Yes
Medicaid:
No If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name:
Last Name:
Address:
City:
Phone:
Fax:
No If yes, provide ID #:
(Circle one): M.D. D.O. N.P. P.A.
State:
St Lic #:
Provider E-mail:
Yes
Yes
No
Carrier Name:
NPI #:
DEA #:
UPIN:
Office Contact Name:
Specialty (Check one):
Rheumatologist
ZIP:
Phone:
Other:
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
Place of Administration:
Self-administered
Physician’s Office
Dispensing Provider/Pharmacy: Patient Selected choice
Physician’s Office
Specialty Pharmacy
Other:
Retail Pharmacy
Mail Order
Name:
Administration code(s) (CPT):
Phone:
TIN:
E. PRODUCT INFORMATION
Request is for:
Xeljanz 5 mg
Dose:
Fax:
PIN:
Frequency:
F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other any other where applicable (*).
Primary ICD Code:
714.0 Rheumatoid Arthritis
714.2 Other Rheumatoid Arthritis with visceral or systemic involvement
Secondary ICD Code:
Other:
G. CLINICAL INFORMATION - Required clinical information must be completed for ALL precertification requests.
Yes
Yes
Yes
No
Is the patient an adult with moderately to severely active rheumatoid arthritis?
No
Has the patient had an inadequate response or intolerance to methotrexate?
No
Does the patient have a documented recent tuberculin skin test (within 6 months) to check for latent tuberculosis?
If yes: Date of TB test:
/
/
Yes
No
Does the patient have a contraindication, intolerance or incomplete response to any of the following?
If yes, check ALL that apply:
Enbrel
Humira
Remicade
Yes
No
Will the patient use tofacitinib (Xeljanz) in combination with a biologic disease-modifying anti-rheumatic drug (DMARD)?
Yes
No
Will the patient use tofacitinib (Xeljanz) in combination with azathioprine, cyclosporine or other potent immunosuppressant?
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-68856-1 (12-14)