Drug Prior Authorization Form Secukinumab (Cosentyx)

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Drug Prior Authorization
secukinumab (COSENTYX)
STEP 1: CLEARLY PRINT AND COMPLETE TO EXPEDITE PROCESSING
Date:
Prescriber First
& Last Name:
Patient First
Prescriber NPI:
& Last Name:
Patient Address:
Prescriber Address:
Patient ID:
Prescriber Phone:
Patient Birth Date:
Prescriber Fax:
STEP 2: COMPLETE REQUIRED CRITERIA
Indicate Primary Diagnosis: ___________________________________ ICD 10 Code: ___________
Initial Therapy – 3 Month Approval (ALL criteria must be met)
Prescribed by a Dermatologist
AND
Patient has (indicate at least one):
Moderate to severe Plaque Psoriasis (>10% body surface involved) AND significant
functional disability
OR
Debilitating Palmar/Plantar Psoriasis
AND
Failed a minimum of 15 sessions of phototherapy or phototherapy contraindicated
AND
Failed methotrexate (minimum dose of 15mg/week) OR failed soriatane
AND
Failed HUMIRA (adalimumab)
AND
Supporting chart notes or documentation submitted with this request, such as:
 Documentation of disease severity and progression
 Medication dose, duration, response, adverse reactions or contraindications
 Phototherapy type, duration, response, adverse reactions or contraindications
Continuing Therapy – 1 Year Approval (ALL criteria must be met)
Prescribed by a Dermatologist
AND
Patient has demonstrated a significant improvement in his/her psoriatic condition
AND
Documented (written explanation accepted) improvement within the past year
submitted with this request (Documentation is required for approval)
STEP 3: SPECIALTY PHARMACY REQUIRED
Specialty Pharmacy (Please Complete Page 3 Prescription Form)
12/17/2015
Version 1.0

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