Medical Necessity Request Form Page 2

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Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Safety/Contraindication Information:
1. Will the member be concurrently receiving this medication with another Biological Response Modifier (BRM), Tofacitinib
(Xeljanz/Xeljanz XR) or Apremilast (Otezla)? Yes or No
- If yes, Please give the drug name and the reason for receiving more than one BRM or Xeljanz:
________________________________________________________________________________________________________
Please indicate if the member has any of the contraindications listed for the requested drug.
Enbrel
Remicade
Kineret
Xeljanz/Xeljanz XR
Tysabri
□ Known Sepsis
□ Previous severe
□ Known
□ Concurrent use of a Disease
□ Concurrent use of a Disease Modifying
hypersensitivity reaction
hypersensitivity to
Modifying Antirheumatic Drug
Antirheumatic Drug (DMARD) or potent
□ NONE
to Remicade
E. coli-derived
(DMARD) or potent
immunosuppressant (e.g., azathioprine,
proteins
immunosuppressant (e.g.,
tacrolimus, cyclosporine) or TNF-alpha
□ Moderate to severe
azathioprine, tacrolimus,
inhibitors (e.g Humira, Enbrel, Remicade,
□ NONE
heart failure
cyclosporine)
Simponi, Cimzia)
□ NONE
□ NONE
□ Previous or current progressive
multifocal leukoencephalopathy (PML)
□ NONE
Remicade requests only:
For diagnoses of Rheumatoid Arthritis, Psoriatic Arthritis, Plaque Psoriasis, Ankylosing Spondylitis, and Non-Fistulizing Crohn’s
Disease:
- Can the member try either Enbrel or Humira instead of Remicade? Yes or No
- If no, please provide the clinical reason why the member cannot try either Enbrel or Humira:
__________________________________________________________________________________________
- If yes, please call the prescription in to the pharmacy and fill out this form and send to horizon
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
2 of 3
Rev. 3/16
HNJH Fax #: 888-567-0681
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