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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Ilaris NTL PAB Fax Form 10.12.15.doc