Form Gr-68774 - Medication Precertification Request Form Page 2
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1
2®
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 2 of 2
(All fields must be completed and legible for Precertification Review.)
For Medicare Advantage Part B:
FAX:
1-844-268-7263
Patient First Name
Patient Last Name
Patient Phone
Patient DOB
G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests.
Yes
No Does the patient have a documented diagnosis of CD30+ peripheral T-cell lymphoma (PTCL)?
If yes,
Yes
No
Is Adcetris being used as second-line or subsequent therapy?
If yes, please select which one:
second-line therapy
subsequent therapy
Yes
No Does the patient have a documented diagnosis of CD30+ relapsed or refractory diffuse large B-cell lymphoma?
If yes, please select which one:
Relapse
Refractory
Yes
No
Is the patient a candidate for high-dose therapy?
Yes
No
Is Adcetris being used as second-line or subsequent therapy?
If yes, please select which one:
second-line therapy
subsequent therapy
Yes
No Does the patient have a documented diagnosis of CD30+ AIDS-related diffuse large B-cell lymphoma, primary effusion lymphoma, or
lymphoma associated with Castleman’s disease?
If yes, please indicate which of the following pertains to the patient:
CD30+ AIDS-related diffuse large B-cell lymphoma
Primary effusion lymphoma
Lymphoma associated with Castleman’s disease
Yes
No
Is the patient a candidate for high-dose therapy?
Yes
No
Is Adcetris being used as second-line or subsequent therapy?
If yes, please select which one:
second-line therapy
subsequent therapy
Yes
No Does the patient have a documented diagnosis of mycosis fungoides/Sezary syndrome?
If yes,
Yes
No
Will Adcetris be used as first line chemotherapy?
Yes
No Does the patient have a documented diagnosis of CD30+ relapsed or refractory primary cutaneous leg type diffuse large B-cell
lymphoma?
If yes, please select which one:
Relapse
Refractory
Yes
No
Is the patient a candidate for high-dose therapy?
Yes
No
Is Adcetris being used as second-line or subsequent therapy?
If yes, please select which one:
second-line therapy
subsequent therapy
Yes
No Does the patient have a documented diagnosis of primary cutaneous anaplastic large cell lymphoma (ALCL)?
If yes,
Yes
No
Is there clinical evidence of multifocal lesions?
Yes
No
Will Adcetris be used as a single-agent therapy?
Yes
No Does the patient have a documented diagnosis of cutaneous anaplastic large cell lymphoma (ALCL) with regional nodes?
If yes,
Yes
No
Will Adcetris be used as a single-agent therapy?
Yes
No Does the patient have a documented diagnosis of symptomatic lymphomatoid papulosis (LyP)?
If yes,
Yes
No
Will Adcetris be used as a single-agent therapy?
Yes
No Does the patient have a documented diagnosis of symptomatic lymphomatoid papulosis (LyP) with extensive lesions?
If yes,
Yes
No
Is the patient refractory to all primary treatment options?
Yes
No
Will Adcetris be used as a single-agent therapy?
For Continuation:
Yes
No
Has the patient developed intolerance or toxicity to the drug?
If yes, please indicate the intolerance or toxicity the patient has experienced:
Anaphylaxis and infusion reactions
Embryo-fetal toxicity
Hematologic toxicities
Hepatotoxicity
Infections/ opportunistic infections
Peripheral neuropathy
Pulmonary toxicity
Stevens-Johnson syndrome
Toxic epidermal necrolysis (TEN)
Tumor lysis syndrome
Other – please explain:
_________________
Yes
No
Has the patient experienced disease progression?
H. ACKNOWLEDGEMENT
Request Completed By (Signature Required):
Date:
/
/
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or
deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading,
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
The plan may request additional information or clarification, if needed, to evaluate requests.
GR-68774 (12-15)
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