Fillable Form Gr-68722 Medication Precertification Request printable pdf download

Aetna Precertification Notification

Belimumab (Benlysta

) Injectable

503 Sunport Lane, Orlando, FL 32809

Medication Precertification Request

Phone: 1-866-503-0857

FAX:

1-888-267-3277

(All fields must be completed and legible for Precertification Review.)

Please indicate:

Start of treatment: Start date

Continuation of therapy: Date of last treatment cycle

Precertification Requested By:

Phone:

Fax:

A. PATIENT INFORMATION

First Name:

Last Name:

Address:

City:

State:

ZIP:

Home Phone:

Work Phone:

Cell Phone:

Allergies:

Email:

DOB:

Current Weight:

lbs or

kgs

Height:

inches or

cms

B. INSURANCE INFORMATION

Aetna Member ID #:

Does patient have other coverage?

Yes

Group #:

If yes, provide ID#:

Carrier Name:

Insured:

Medicare:

Yes

No If yes, provide ID #:

Medicaid:

Yes

No If yes, provide ID #:

C. PRESCRIBER INFORMATION

(Circle one): M.D. D.O. N.P. P.A.

First Name:

Last Name:

Address:

City:

State:

ZIP:

Phone:

Fax:

St Lic #:

NPI #:

DEA #:

UPIN:

Provider Email:

Office Contact Name:

Phone:

Specialty (Check one):

Rheumatologist

Other:

D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION

Place of Administration:

Dispensing Provider/Pharmacy: (Patient selected choice)

Self-administered

Physician’s Office

Retail Pharmacy

Specialty Pharmacy

Mail Order

Outpatient Infusion Center

Phone:

Other:

Center Name:

Home Infusion Center

Phone:

Name:

Agency Name:

Phone:

Fax:

TIN:

PIN:

Administration code(s) (CPT):

E. PRODUCT INFORMATION

Request is for Benlysta: Dose:

Frequency:

F. DIAGNOSIS INFORMATION

- Please indicate primary ICD-9 code and specify any other where applicable.

Primary ICD-9:

Secondary ICD-9:

Other ICD-9 Code:

G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests.

Yes

No Is the patient 18 years of age or older with active systemic lupus erythematosus?

Yes

No Does the patient have a positive ANA (anti-nuclear antibody) titer greater than or equal to 1:80 and/or anti-dsDNA (double

stranded DNA) greater than or equal to 30 IU/ml?

Yes

No Is there evidence of severe active lupus nephritis (proteinuria greater than 6 g/24 hour or equivalent using spot urine protein

to creatinine ratio, or serum creatinine greater than 2.5mg/dL)?

Yes

No Does the patient require hemodialysis?

Yes

No Is there evidence of severe active central nervous system lupus (seizures, psychosis, organic brain syndrome,

cerebrovascular accident, cerebritis or CNS vasculitis requiring therapeutic intervention with 60 days of day 0)?

Yes

No Does the patient require high-dose prednisone (greater than 100mg/day)?

Yes

No Is the patient currently being treated with intravenous cyclophosphamide?

Yes

No Is the patient currently being treated with rituximab or any other B cell targeted therapy?

Yes

No Does the patient’s current therapy include any of the following (alone or in combination): anti-malarials, corticosteroids,

immunosuppressives and/or non-steroidal anti-inflammatory drugs?

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.

GR-68722 (1-13)

Form Gr-68722 Medication Precertification Request

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