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

of 3

For Medicare Advantage Part B: FAX: 1-844-268-7263

(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: Phone: Fax:

A. PATIENT INFORMATION

First Name: Last Name:

Address: City: State: ZIP:

Home Phone: Work Phone: Cell Phone:

DOB: Allergies: E-mail:

Current Weight: lbs or kgs Height: inches or cms

B. INSURANCE INFORMATION

Member ID #:

Group #:

Insured:

Does patient have other coverage? Yes No

If yes, provide ID#: Carrier Name:

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. P.A.

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:

Self-administered Physician’s Office

Outpatient Infusion Center Phone:

Center Name:

Home Infusion Center Phone:

Agency Name:

Administration code(s) (CPT):

Address:

Dispensing Provider/Pharmacy: Patient Selected choice

Physician’s Office Retail Pharmacy

Specialty Pharmacy Mail Order

Other:

Name:

Address:

Phone: Fax:

TIN: PIN:

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.

Is/ Will rituximab (Rituxan) be used concomitantly with apremilast, tofacitinib, or other biologic DMARDs (e.g., adalimumab, infliximab)? Yes No

Acute lymphoid leuke mia

Does the patient have a documented diagnosis of Philadelphia chromosome-negative acute lymphoid leukemia (ALL)? Yes No

Is rituximab (Rituxan) being used as induction/consolidation therapy? Yes

No

Autoimmune hemolytic anemia

Does the patient have a documented diagnosis of refractory autoimmune hemolytic anemia? Yes No

Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides

Please indicate which of the following applies to the patient: Wegener granulomatosis Churg-Strauss syndrome

microscopic polyangiitis pauci-immune glomerulonephritis

Has the patient had an inadequate response to cyclophosphamide? Yes No

Will Rituxan be given in conjunction with glucocorticoids? Yes No

Autoimmune blistering diseases, corticosteroid-refractory

Please select which applies to the patient: pemphigus vulgaris pemphigus folliaceus bullous pemphigoid cicatricial pemphigoid

epidermolysis bullosa acquisita paraneoplastic pemphigus None of the above

Castleman's disease

Does the patient have a documented diagnosis of multicentric Castleman’s disease (angiofollicular lymph node hyperplasia)? Yes No

Chronic or small lymphocytic leukemia

Please select which applies to the patient: chronic lymphocytic leukemia (CLL) small lymphocytic leukemia

Cryoglobulinemia

Does the patient have a documented diagnosis of cryoglobulinemia? Yes No

Is there clinical documentation that the treatment with corticosteroids and other immunosuppressive agents was ineffective? Yes No

Graft versus host disease, chronic

There is documentation that rituximab (Rituxan) is being used as last-resort treatment for chronic graft versus host disease (GVHD)? Yes No

Hairy cell leukemia

Please select which applies to the patient: relapsed hairy cell leukemia refractory hairy cell leukemia Other, please explain:

Was treatment with at least two courses of cladribine ineffective? Yes

Please provide the date range of course #1: Date range:

Please provide the date range of course #2: Date range:

No

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GR-68535 (11-17)

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Aetna Precertification Notification Rituxan® (rituximab) Medication 503 Sunport Lane, Orlando, FL 32809

Phone: 1-866-503-0857 Precertification Request FAX: 1-888-267-3277

of 3 (All fields must be completed and return both pages for precertification review) For Medicare Advantage Part B:

FAX: 1-844-268-7263

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Patient First Name Patient Last Name Patient Phone Patient DOB

G. CLINICAL INFORMATION (Continued) - Required clinical information must be completed for ALL precertification requests.

Heart and solid organ transplant

Please select which applies to the patient: heart transplant recipient other solid organ transplant recipient

Is there a documentation that rituximab (Rituxan) is being used for treatment or prevention (desensitization) of highly sensitized patients with

antibody mediated rejection in heart transplant recipients and other solid organ transplant recipients?

Yes No

Immune or idiopathic thrombocytopenic purpura

Does the patient have a documented diagnosis of refractory immune or idiopathic thrombocytopenic purpura (ITP)?

refractory immune thrombocytopenic purpura idiopathic thrombocytopenic purpura (ITP)

Yes No

Kidney transplant, rejection prophylaxis

Is rituximab (Rituxan) being used as rejection prophylaxis in sensitized kidney transplant recipients with donor specific antibodies? Yes No

Lymphocyte-predominant Hodgkin's lymphoma

Does the patient have a documented diagnosis of lymphocyte-predominant Hodgkin’s lymphoma? Yes No

Multiple Sclerosis

Please indicate the type of multiple sclerosis the patient has been diagnosed with:

Relapsing-remitting MS (RRMS) Secondary-progressive MS (SPMS) Primary-progressive MS (PPMS) Progressive-relapsing MS (PRMS)

Has the patient discontinued other medications used for treating MS (not including Ampyra)? Yes No

Is there documentation that Rituxan is being used as last-resort treatment? Yes No

Has the patient had an inadequate response to medications used to treat multiple sclerosis? Yes

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 Other:

daclizumab (Zinbryta) : Please indicate the date range of trial:


dimethyl fumarate (Tecfidera) : Please indicate the date range of trial:


glatiramir acetate (Copaxone or Glatopa): Please indicate the date range of trial:


fingolimod (Gilenya): Please indicate the date range of trial:


interferon beta-1a (Avonex, Rebif): Please indicate the date range of trial:


interferon beta-1b (Betaseron, Extavia): Please indicate the date range of trial:


natalizumab (Tysabri): Please indicate the date range of trial: / / - / /


ocrelizumab (Ocrevus): Please indicate the date range of trial:

Please define the failure of therapy*: Increasing relapses Lesion progression by MRI Worsening disability Other:

teriflunomide (Aubagio): Please indicate the date range of trial:


No

* Increasing relapses: defined as two or more r elapses in a year, or one sev ere relapse associated with either p oor 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 b y sustained worsening of E xpanded Disability S tatus Scale ( EDSS) sc ore or n eurological examination findings

Neuromyelitis optica

Does the patient have a documented diagnosis of neuromyelitis optica? Yes No

Was the treatment with at least one immunotherapy was ineffective? Yes No

Non-Hodgkin's lymphoma

Does the patient have a documented diagnosis of non-Hodgkin’s lymphoma (NHL)? Yes No

Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)

Does the patient have a documented diagnosis of opsoclonus-myoclonus-ataxia (OMA) associated with neuroblastoma? Yes

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No

Is the patient refractory to steroids, chemotherapy and intravenous immunoglobulins? Yes

Please provide the names and date ranges of medications tried:

Medication: Dates:

Medication: Dates:

Medication: Dates:

No

Post-transplant lymphoproliferative disorder

Does the patient have a documented diagnosis of post-transplant lymphoproliferative disorder? Yes No

Continued on next page

GR-68535 (11-17)

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Aetna Precertification Notification Rituxan® (rituximab) Medication 503 Sunport Lane, Orlando, FL 32809

Phone: 1-866-503-0857 Precertification Request FAX: 1-888-267-3277

of 3 (All fields must be completed and return both pages for precertification review) For Medicare Advantage Part B:

FAX: 1-844-268-7263

Patient First Name Patient Last Name Patient Phone Patient DOB

G. CLINICAL INFORMATION (Continued) Required clinical information must be completed for ALL precertification requests.

Sjögren syndrome

Does the patient have a documented diagnosis of Sjögren’s syndrome?Yes No

Was treatment with corticosteroids and other immunosuppressive agents ineffective?Yes

Please provide the names and dates of the corticosteroids and other immunosuppressive agents used:

Medication: Dates: / / - / /

Medication: Dates: / / - / /

No

Thrombotic thrombocytopenic purpura

Does the patient have a documented diagnosis of refractory thrombotic thrombocytopenic purpura (TTP)? Yes No

Waldenstrom’s macroglobulinemia

Does the patient have a documented diagnosis of Waldenström macroglobulinemia? Yes No

Rheumatoid Arthritis

Please indicate the severity of the patient’s rheumatoid arthritis: Mild Moderate Severe

Is there evidence that the disease is active? Yes No

Was treatment with Enbrel ineffective? Yes

Please provide the date range of the trial: Date range:

Was the treatment with Enbrel not tolerated or contraindicated?

/ / - / /

not tolerated contraindicated Yes No

No

Was treatment with Inflectra ineffective? Yes


Was the treatment with Inflectra not tolerated or contraindicated? not tolerated contraindicated Yes No

No

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Was treatment with Remicade ineffective? Yes

Please provide the date range of the trial: Date range: / / - / /

Was the treatment with Remicade not tolerated or contraindicated? not tolerated contraindicated Yes No

No

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Was treatment with Renflexis ineffective? Yes


Was the treatment with Renflexis not tolerated or contraindicated? not tolerated contraindicated Yes No

No

Was treatment with Simponi ineffective? Yes

/ / - / /Please provide the date range of the trial: Date range:

Was the treatment with Simponi not tolerated or contraindicated? not tolerated contraindicated Yes No

No

Was treatment with Simponi Aria ineffective? Yes


Was the treatment with Simponi Aria not tolerated or contraindicated? not tolerated contraindicated Yes No

No

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Was treatment with Xeljanz/Xeljanz XR ineffective? Yes

Please provide the date range of the trial: Date range: / / - / /

Was the treatment with Xeljanz/Xeljanz XR not tolerated or contraindicated? not tolerated contraindicated Yes No

No

Will rituximab be used in combination with methotrexate?Yes No

For Continuation Request:

Is this continuation request a result of the patient receiving samples of rituximab (Rituxan)? (Sampling of Rituxan does not guarantee coverage under the provisions of the pharmacy benefit)

Yes No

For rheumatoid arthritis and multiple sclerosis only:

Please indicate the length of time on therapy:

Is there clinical documentation supporting disease stability? Yes No

Is there clinical documentation supporting disease improvement? Yes No

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-68535 (11-17)

rituxan® (rituximab) medication precertification request

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