Ilaris (Canakinumab) Prior Authorization Of Benefits (Pab) Form

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CONTAINS CONFIDENTIAL PATIENT INFORMATION
Ilaris (canakinumab)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: __________________________________
Prescribing Physician: ____________________________
Patient ID #:
__________________________________
Physician Address:
_____________________________
Patient DOB: __________________________________
Physician Phone #:
_____________________________
Date of Rx:
__________________________________
Physician Fax #:
_____________________________
Patient Phone #: _______________________________
Physician Specialty:
____________________________
Patient Email Address: ___________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
_________________
Ilaris (canakinumab)
______________________
Specify: _________________
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
A RESPONSE IS REQUIRED FOR EACH OF THE FOLLOWING:
Yes
No
Ilaris (canakinumab) is being used in combination with other biologic disease-modifying antirheumatic
drugs (DMARDs) such as IL-1R antagonists, or an IL-6 receptor antagonists, Janus kinase inhibitors
(for example, Xeljanz [tofacitinib citrate]), or tumor necrosis factor (TNF) antagonists
Yes
No
Patient has had a tuberculin skin test (TST) or Centers for Disease Control and Prevention (CDC)-
recommended equivalent to evaluate for latent tuberculosis prior to initiating canakinumab
Yes
No
Patient has Tuberculosis, an invasive fungal infection, or other active serious infections or a history of
recurrent infections
Diagnosis of Cryopyrin-Associated Periodic Syndrome (CAPS)
Yes
No
Patient has a diagnosis of Cryopyrin-Associated Periodic Syndrome (CAPS)
Yes
No
Patient’s diagnosis of Cryopyrin-Associated Periodic Syndrome (CAPS) includes Familial Cold
Autoinflammatory Syndrome (FCAS)
Yes
No
Patient’s diagnosis of Cryopyrin-Associated Periodic Syndrome (CAPS) includes Muckle-Wells
Syndrome (MWS)
Yes
No
Patient is 4 years of age or older
Diagnosis of Systemic Juvenile Idiopathic Arthritis (SJIA)
Yes
No
Patient has a diagnosis of active Systemic Juvenile Idiopathic Arthritis (SJIA)
Yes
No
Ilaris (canakinumab) is being used to reduce signs or symptoms OR to induce or maintain clinical
response
Yes
No
Patient has failed to respond to, is intolerant of, or has a medical contraindication to 1 or more
corticosteroids or nonsteroidal anti-inflammatory drugs (NSAIDs)
Yes
No
Ilaris (canakinumab) is being used alone or in combination with corticosteroids, methotrexate (MTX),
or NSAIDs
Yes
No
Patient 2 years of age or older
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CONTINUED ON PAGE 2
Ilaris NTL PAB Fax Form 10.12.15.doc

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