Fillable Prior Authorization Request Form (Page 2 of 3) in pdf

Enbrel-Humira-Remicade-Orencia-Kineret-Simponi-Cimzia-Actemra-Stelara

_____________________________

OptumRx

Patients Name:

Page 2 of 2

Fax # 1-800-853-3844

_____________________________

__________

Patients ID#:

DOB:

OptumRx Specialty Prior Authorization (continued)

Document the patient’s diagnosis: _____________________________ ICD-9 Code _____________________________

Please Document all that applies to the Patient

Has the patient been evaluated for tuberculosis and treated accordingly?

Yes

Document date of last PPD test:

Negative

Positive

For Diagnosis of Rheumatoid Arthritis or Ulcerative Colitis: Does the Patient exhibit symptoms of MODERATE to SEVERE?

Yes

For Diagnosis of Psoriasis: Does the patient have failure, intolerance or contraindication to: (Please check all that apply)

Ultraviolet Light B (UVB),

Pulsed Dye Laser,

Photochemotherapy,

Psoralen and

exposure to Ultraviolet light a (PUVA)

Yes

For Diagnosis of Crohn’s Disease: Does the patient exhibit symptoms of MODERATE to SEVERE?

Has induction dose been prescribed?

Yes

(if NO document reason why it has not been prescribed)

Document if the patient has tried, failed or had contraindication

Methotrexate

6- mercaptopurine (Purnethol)

Imuran (azathioprine)

NSAIDs (e.g. Ibuprofen)

Cyclosporine (Sandimmune, Neoral)

6- thioguanine

Gold compounds (Myochrisine, Ridura, Aurolate, and Solganal)

Acitretin (soriatane)

Plaquenil (hydroxychloroquine)

Hydroxyurea (hydrea)

Arava (leflonomide)

Mycophenolate(cellcept)

Cuprimine (penicillamine)

Corticosteroids

Aminosalicylates (e.g. sulfasalazine, azulfidine, mesalamine)

_____________________________

Please Document Dates of therapies for medications selected:

_____________________________

Please document any clinical contraindications to these medications:

Has the patient had a trial, failure or contraindication to any of the following medications? (Please list dosage and/or contraindication)

Dosage / Contraindication

Enbrel

Yes

Humira

Yes

Remicaid

Yes

Orencia

Yes

Kineret

Yes

Simponi

Yes

Cimzia

Yes

Actemra

Yes

Stelara

Yes

Other

Please list...

Yes

Continuation of Therapy

Yes

Has the patient utilized the medication in the past 45 days?

Yes

Has the patient had documented clinical improvement from ongoing therapy?

(Please document dose reduction or reason for high dose [if applicable])

*If the above information is not available, please attach the patient’s chart notes documenting clinical improvement.

*If you have any questions regarding your patient’s plan drug limits you may call us at: 1-800-711-4555

For UHC members: Your patient’s prescription benefit requires that we review certain requests for coverage with the prescriber. You have prescribed a

medication for your patient that requires Prior Authorization before benefit coverage can be provided. Please complete the following questions then fax this

form to the toll free number listed below. Upon receipt of the completed form, prescription benefit coverage will be determined based on the plan’s rules

his electronic fax transmission, including any attachments contains information from OptumRx that may be confidential and/or privileged. The information

contained in this facsimile is intended to be for the sole use of the individual(s) or entity named above. If you are not the intended recipient, be aware that

any disclosure, copying, distribution or use of the contents of this information is strictly prohibited by law and will be vigorously prosecuted. If you have

received this electronic fax transmission in error, please notify the sender immediately and return the document(s) by mail to OptumRx Privacy Office, 2300

Main

St.,

M/S

CA134-0501,

Irvine,

92614

Enbrel-Humira-Kineret-Orencia-Remicade-Simponi-Cimzia-Actemra-

Stelara_2012June.doc