Form Gr-68774 - Medication Precertification Request Form

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®
Brentuximab vedotin (Adcetris
) Injectable
Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Medication Precertification Request
Phone: 1-866-503-0857
FAX:
1-888-267-3277
Page 1 of 2
(All fields must be completed and legible for Precertification Review.)
For Medicare Advantage Part B:
Please indicate:
Start of treatment: Start date
/
/
FAX:
1-844-268-7263
Continuation of therapy: Date of last treatment
/
/
Precertification Requested By:
Phone:
Fax:
A. PATIENT INFORMATION
First Name:
Last Name:
Address:
City:
State:
ZIP:
Home Phone:
Work Phone:
Cell Phone:
DOB:
Allergies:
E-mail:
Current Weight:
lbs or
kgs
Height:
inches or
cms
B. INSURANCE INFORMATION
Aetna Member ID #:
Does patient have other coverage?
Yes
No
Group #:
If yes, provide ID#:
Carrier Name:
Insured:
Insured:
Medicare:
Medicaid:
Yes
No
If yes, provide ID #:
Yes
No
If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name:
Last Name:
(Check One):
M.D.
D.O.
N.P.
P.A.
Address:
City:
State:
ZIP:
Phone:
Fax:
St Lic #:
NPI #:
DEA #:
UPIN:
Provider E-mail:
Office Contact Name:
Phone:
Specialty (Check one):
Oncologist
Other:
_______________________________________
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
Place of Administration:
Dispensing Provider/Pharmacy: Patient Selected choice
Self-administered
Physician’s Office
Physician’s Office
Retail Pharmacy
Outpatient Infusion Center
Phone:
Specialty Pharmacy
Mail Order
Center Name:
Other:
Home Infusion Center
Phone:
Name:
Agency Name:
Phone:
Fax:
Administration code(s) (CPT):
TIN:
PIN:
E. PRODUCT INFORMATION
Request is for Adcetris: Dose:
Frequency:
F. DIAGNOSIS INFORMATION – Please indicate primary ICD Code and specify any other where applicable.
Primary ICD Code:
Secondary ICD Code:
Other ICD Code:
G. CLINICAL INFORMATION – Required clinical information must be completed in its entirety for all precertification requests.
For Initiation:
Yes
No
Is Adcetris being used as salvage therapy for a patient with the diagnosis of classical Hodgkin lymphoma?
If yes,
Yes
No
Has the patient experienced failure of autologous stem cell transplant (ASCT)?
Please provide the date of the transplant:
/
/
Yes
No
Has the patient tried and failed at least 2 multi-agent chemotherapeutic regimens?
Please indicate the first chemotherapy regimen and dates tried:
Dates tried:
/
/
,
/
/
,
/
/
Please indicate the second chemotherapy regimen and dates tried:
Dates tried:
/
/
,
/
/
,
/
/
Yes
No
Is Adcetris being used as maintenance therapy for a patient with the diagnosis of classical Hodgkin lymphoma?
If yes,
Yes
No
Is the patient’s lymphoma primary refractory disease?
Yes
No
Did the patient relapse less than 12 months following primary therapy?
If yes, please indicate the chemotherapy the patient was on:
Yes
No
Has the patient had autologous stem cell rescue and high-dose chemotherapy?
If yes, please enter date of the date of the transplant:
/
/
Yes
No
Has the patient received brentuximab vedotin (Adcetris) in past?
Yes
No Does the patient have a documented diagnosis of relapsed or refractory systemic anaplastic large cell lymphoma (ALCL)?
If yes, please select which one:
Relapse
Refractory
Yes
No
Is the patient’s ALCL the cutaneous form?
Yes
No
Is Adcetris being used as second-line or subsequent therapy?
If yes, please select which one:
second-line therapy
subsequent therapy
Continued on next page
GR-68774 (12-15)

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