Actemra (Tocilizumab) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Actemra (tocilizumab)
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
Actemra (tocilizumab)
_______________
__________________________
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
Has the patient had Tuberculosis, invasive fungal infection, or other active serious infections, or a
history of recurrent infections?
□
□
Yes
No
Has the patient had a tuberculin skin test (TST), or a Centers for Disease Control and Prevention
(CDC)-recommended equivalent, to evaluate for latent Tuberculosis prior to initiating Actemra
(tocilizumab)?
□
□
Yes
No
Will the patient be using Actemra (tocilizumab) in combination with other biologic disease
modifying anti-rheumatic drugs (DMARDs) such as anti-CD20 monoclonal antibodies, IL-1R
antagonists, Janus kinas inhibitors (for example, tofacitinib citrate), selective co-stimulation
modulators, or TNF antagonists?
□
□
3
Yes
No
Does the patient have an absolute neutrophil count (ANC) less than 2000/mm
, platelet count less
3
than 100,000/mm
, or ALT or AST above 1.5 times the upper limit of normal (ULN)?
Rheumatoid Arthritis (RA):
□
□
Yes
No
Is the patient 18 years of age or older?
□
□
Yes
No
Does the patient have moderately to severely active rheumatoid arthritis?
□
□
Yes
No
Is Actemra (tocilizumab) being used for any of the following reasons: to reduce signs or symptoms,
to induce or maintain clinical response, to inhibit the progression of structural damage, or to improve
physical function?
□
□
Yes
No
Has the patient had an inadequate response to a trial of 1 or more disease modifying anti-rheumatic
drugs (DMARDs) (for example, methotrexate [MTX]) or a tumor necrosis factor [TNF] antagonist
drug
□
□
Yes
No
Will the patient be using Actemra (tocilizumab) alone or in combination with MTX or with other non-
biologic DMARDs?
□
□
Yes
No
Has the patient had an inadequate response to 2 preferred biologic therapies in the previous 180
days? (please indicate):
□
□
□
□
Enbrel (etanercept)
Humira (adalimumab)
Remicade (infliximab)
Simponi (golimumab)
PAGE 1 OF 2 - CONTINUED ON PAGE 2
Actemra NTL PAB Fax Form 10.12.15.doc
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