Immune Modulating Drugs Prior Authorization Request Form

(1)

Patient:

HPHC member ID #:

Requesting provider:

Requesting provider NPI:

Phone:

Fax:

Servicing provider:

Servicing provider NPI:

Diagnosis:

ICD 10 code:

Contact for questions (name and phone #):

Projected start and end date for requested treatment:

ActemrA® (tocilizumAb)

D

iAgnosis

(C

heCkallthatapply

):

c

linicAlAnD

D

osing

i

nformAtion

(C

):

reQuireD

Check the appropriate treatment:

New Start (Drug Naïve) Ongoing treatment or Reauthorization

reQuireD

Rheumatoid Arthritis (RA)

Systemic juvenile idiopathic arthritis (SJIA)

Polyarticular Juvenile Idiopathic Arthritis (PJIA)

Other (please specify):

reQuireD

Concurrent treatment with traditional DMARD

agent (e.g., azathioprine, cyclosporine,

d-penicil-lamine, gold sodium, thiomalate, methotrexate,

auranofin, aurothioglucose, hydroxychloroquine,

leflunomide, and sulfasalazine)

Treatment failure with traditional DMARD agent

Contraindication to traditional DMARD agent

Treatment failure with Enbrel® (etanercept) or

Humira™ (adalimumab)

Contraindication to Enbrel® or Humira™

Required

–– Dose and Dosing Interval:

Reauthorization request must include evidence of symptom improvement(s):

cimziA® (certolizumAb pegol)

D

iAgnosis

(C

):

c

linicAlAnD

D

osing

i

nformAtion

(C

):

reQuireD

New Start (Drug Naïve) Ongoing treatment or reauthorization

reQuireD

Ankylosing Spondylitis Crohn’s Disease Psoriatic Arthritis Rheumatoid Arthritis Other (please specify):

reQuireD

Treatment failure with, or contraindication to: Corticosteroids (e.g. prednisone, prednisolone, methylprednisolone, budesonide)

5-Aminosalicylates (e.g. sulfasalazine, mesalamine, olsalazine, balsalazide)

Immunosupressants/immunomodulators (e.g.

6-mer-FAX: 800-232-0816

For Buy and Bill Physician Administered Drugs Only

For the subcutaneous

formulation of this drug

please contact MedImpact

for authorization at

800-788-2949.

(2)

e

ntyvio

(vedolizumab)

reQuireD

Chron’s Disease Ulcerative Colitis

reQuireD

Treatment failure with, or contraindication to two or more:

Corticosteroids (e.g., prednisone, prednisolone, methylprednisolone)

5-Aminosalicylates (e.g., balsalazide disodium, sul-fasalazine, Azulfidine, Apriso, Delzicol,Pentasa, Rowasa, Dipentum, Colazal)

6-mercaptopurine (6-MP, Purinethol) and or azathio-prine, (Imuran)

Methotrexate

And

Treatment failure or contraindication to tumor necrosis factor (tnf) blocker (e.g., Remicade, Humira)

i

lAris

® (canakinumab)

D

iAgnosis

(C

):

c

linicAlAnD

D

osing

i

nformAtion

(C

):

reQuireD

Cryopyrin-associated periodic syn-dromes (CAPS) including familial cold auto-inflammatory syndrome (FCAS) and Muckle-Wells syndrome Systemic Juvenile Idiopathic Arthri-tis (SJIA)

reQuireD

Treatment failure with, or contraindication to: One or more Corticosteriods or NSAIDs

Required

— Dose and Dosing Interval:

If obtaining through

Accredo Specialty Pharmacy,

please contact MedImpact

for authorization at

800-788-2949.

(3)

o

renciA

™ (abatcept)

D

iAgnosis

(C

heCk all that apply

):

c

linicAlAnD

D

osing

i

nformAtion

(C

heCk all that apply

):

reQuireD

Rheumatoid Arthritis

Active polyarticular juvenile idio-pathic arthritis

reQuireD

Treatment failure with traditional DMARD agent (aza-thioprine, cyclosporine, d-penicillamine, gold sodium, thiomalate, methotrexate, auranofin, aurothioglucose, hydroxychloroquine, leflunomide, sulfasalazine) Contraindication to traditional DMARD agent

Treatment failure with biological DMARD agent (e.g., Cimzia® [certolizumab], Kineret® [anakinra], Orencia™ [abatacept], Remicade® [infliximab], Simponi [golim-umab]).

Contraindication to biological DMARD agent Previous treatment failure with Enbrel® or Humira™.

Required

–– Dose and Dosing Interval:

(Continued)

For the subcutaneous

formulation of this drug

please contact MedImpact

for authorization at

(4)

Remicade (imfliximab )

D

iAgnosis

(c

heckAllthAtApply

):

c

linicAlAnDDosinginformAtion

(c

):

reQuireD

Moderately to severely active rheu-matoid arthritis

Active psoriatic arthritis

Moderately to severely active Crohn’s Disease

Fistulizing Crohn’s Disease

Moderately to severely active ulcer-ative colitis

Active ankylosing spondylitis Severe (extensive, disabling) plaque psoriasis

reQuireD

Treatment failure with oral or injectable DMARD agent (e.g., azathioprine, cyclosporine, d-penicillamine, gold sodium thiomalate, methotrexate, auranofin, aurothio-glucose, hydroxychloroquine, leflunomide, sulfasala-zine)

Contraindication to one oral or injectable DMARD agent

Treatment failure with:

Corticosteroids (e.g., prednisone, prednisolone, methylprednisolone)

5-Aminosalicylates (e.g. sulfasalazine, mesalamine, olsalazine, balsalazide)

Immunosupressants/immunomodulators (e.g., 6-mer-captopurine, azathioprine, methotrexate)

Prescription NSAID

Systemic therapy for psoriasis (e.g., acitretin, aza-thioprine, cyclosporine, hydroxyurea, methotrexate, Mycophenolate mofetil, oral methoxsalen plus UVA light [PUVA], propylthiouracil, sulfasalazine, tacroli-mus, 6-thioguanine)

Previous treatment failure with Humira™ Previous treatment failure with Enbrel®

Required

–– Dose and Dosing Interval:

(5)

r

ituxAn

(

rituximAb

)

D

iAgnosis

(c

):

c

(c

):

reQuireD

New Start (Drug Naïve) Ongoing treatment or

Reauthorization

reQuireD

Acute Lymphoblastic Leukemia (ALL) Central Nervous System Cancers (CNS)

Chronic Lymphocytic Leukemia (CLL) Neuromyelitis Optica

Non-Hodgkin’s Lymphoma (NHL)* Post-transplant B-lymphoprolifera-tive disorder

Bullous Pemphigoid (refractory)

reQuireD

Authorized when documentation confirms diagnosis. Documentation of prior treatment failure is not required.

Chronic Graft Versus Host Disease

(GVHD Must have all:_{Treatment failure with or contraindication to,} corticosteroids (e.g., prednisone)

Treatment failure with, or contraindication to, a calci-neurin inhibitor (e.g., cyclosporine, tacrolimus) Dermatomyositis Treatment failure with, or contraindication to,

glucocorticoid therapy. Granulomatosis with Polyangiitis

(GPA/Wegener’s Granulomatosis)

Treatment failure with, or contraindication to, metho-trexate and/or cyclophosphamide in combination with glucocorticoids, or

Documented concerns about fertility, high risk of malignancy, relapsing disease or cyclophosphamide resis-tance.

Bullous Pemphigoid (refractory) Treatment failure or contraindication to: Systemic, or high-dose topical steroids, or

Immunosuppressive glucocorticoid-sparing agent (e.g., mycophenolate mofetil, azathioprine, or methotrexate)

Idiopathic thrombocytopenic

pur-pura (ITP) Treatment failure or contraindication to steroid therapy: Corticosteroids

High-dose topical steroids Systemic steroids

Microscopic Polyangiitis (MPA) in adult patients in combination with glucocorticoids

Treatment failure with or contraindication to methotrex-ate and/or cyclophosphamide in combination with gluco-corticoids.

Documented concerns about fertility, high risk of malignancy, relapsing disease or cyclophosphamide resistance.

(6)

r

ituxAn

(

rituximAb

) continued D

iAgnosis

(c

):

c

(c

):

Multiple Sclerosis (MS)

Primary Progressive Relapse remitting Secondary Progressive

Member is < 50 years of age, or

Documentation shows enhancement on MRI Positive serology to JC virus, or

History of previous immunosuppressant therapy, or

History of treatment failure with, or contraindication to, Tysabri (natalizumab

History of previous immunosuppressant therapy, or History of treatment failure with, or contraindication to, at least one second-line or oral MS drug (e.g. Aub-agio [teriflunomide], Tecfidera [dimethylfumarate], or Gilenya [fingolimod])

Polymyositis Treatment failure with, or contraindication to, glucocor-ticoid therapy.

Refractory Pemphigus Vulgaris Confirmed diagnosis in members 18 or older and all of the following:

Failed first-line therapy

Treatment failure with or contraindication to, corticosteroids

Rheumatoid Arthritis (RA) Must have all:

Treatment failure with, or contraindication to, one tra-ditional DMARD agent

Treatment failure with or contraindication to Enbrel® (etanercept) OR Humira™ (adalimumab), and at least one other biological DMARD3

Inadequate response to one or more tumor necrosis factor

Solid Organ Transplant Recipients Documented need to reduce anti-HLA antibodies in mem-ber at high risk of antibody-mediated rejection (e.g., high-ly sensitized patients, patients receiving an ABO incompat-ible organ).

(7)

s

imponi

-A

riA

(g

olimumAb

)

D

iAgnosis

(c

):

c

(c

):

reQuireD

New Start (Drug Naïve) Ongoing treatment or

Reauthorization

reQuireD

Moderately to severely active rheu-matoid arthritis

reQuireD

Treatment failure with or contraindication to oral or injectable traditional DMARD agent (e.g., azathioprine, cyclosporine, d-penicillamine, gold sodium, thiomalate, methotrexate, auranofin, aurothioglucose, hydroxychlo-roquine, leflunomide, and sulfasalazine)

Treatment failure with or contraindication to Enbrel® or Humira™

Required

–– Dose and Dosing Interval:

s

telArA

™ (

ustekinumAb

)

D

iAgnosis

(c

):

c

(c

):

reQuireD

Moderate to severe plaque psoriasis

Active psoriatic arthritis Other:

reQuireD

Treatment failure or contraindication to one course of systemic therapy for psoriasis (e.g., methotrexate, aza-thioprine, acitretin, tacrolimus, cyclosporine, mycophe-nolate mofetil, 6-thioguanine, sulfasalazine, hydroxy-urea, propylthiouracil, oral methoxsalen plus UVA light (PUVA).

Previous treatment failure with Enbrel® or Humira™

Treatment failure with oral or injectable DMARD agent (e.g., Hydroxychloroquine (Plaquenil), Leflunomide (Arava), Cyclosporine (Neoral), Sulfasalzine (Azulfidine), Methotrexate (Rheumatrex, Trexall), Azathioprine (Imu-ran), Cyclophosphamide (Cytoxan), Biologics (Actemra, Cimzia, Kineret, Orencia, Remicade, Rituxan, Simponi) Contraindication to oral or injectable DMARD agent

Required

–– Dose and Dosing Interval:

Reauthorization request must include evidence of

If obtaining through Accredo Specialty Pharmacy,

please contact MedImpact for authorization at

800-788-2949.

For the subcutaneous

formulation of this drug

please contact MedImpact

for authorization at

(8)

t

ysAbri

® (

nAtAlizumAb

)

D

iAgnosis

(c

):

c

(c

):

reQuireD

Multiple sclerosis

Moderately to severely active Crohn’s Disease

reQuireD

Relapsing Multiple Sclerosis

Documentation of anti-JCV antibody testing (include date)

Treatment failure with, or contraindication to at least 2 within the past 6 months

Avonex®, Betaseron®, Copaxone®, Rebif®, Ple-gridy, Aubagio, Gilenya, Tecfidera

Crohn’s Disease

Treatment failure with two (or more) of the following:

Documentation of anti-JCV antibody testing (include date)

Corticosteroids (e.g., Prednisone, prednisolone, methylprednisolone)

5-Aminosalicylates (e.g., Sulfasalazine, Azulfidine®, Delzicol™, Pentasa®, Rowasa®, Dipentum®, Colazal®)

6-Mercaptopurine (6-mp, Purinethol®) and/or azathioprine (Imuran®)

Methotrexate (MTX), and treatment failure with, or contraindication to tumor necrosis factor (TNF) blocking agent (e.g., Cimzia®, Humira® or Remicade®)

Required

–– Dose and Dosing Interval:

Reauthorization request must include evidence of symptom improvement(s) and documentation of anti-JCV antibody testing (include date)