Independence Prior Authorization Form - Stelara
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1Today’s date:________________________________________
Date medication needed: ____________________________
Prior Authorization Form - Stelara
ONLY COMPLETED REQUESTS WILL BE REVIEWED.
Check one:
New start
Continued treatment
Patient information (please print)
Physician information (please print)
Patient name
Prescribing physician
Address
Office address
City, state, ZIP
City, state, ZIP
Patient telephone #
Office contact
Patient ID
Office telephone #
Date of Birth
Weight
Fax #
NPI
No delivery requested; physician will use office supply. Authorization only.
Delivery requested to the physician’s office.
** A copy of the prescription must accompany the medication request for delivery.**
1)
Diagnosis for drug requested (must include ICD-10): ______________________________________________________
2)
Patient medical information
For plaque psoriasis only:
a.
Is the patient’s chronic plaque psoriasis classified as moderate-to-severe?
Yes
No
b.
Does the patient have a current infection?
Yes
No
c.
Is at least 5% of the patient’s body surface area involved (<5% for sensitive areas)?
Yes
No
If yes, list affected areas:_______________________________________________________________
d.
Does the patient have a documented history of failure, contraindication, or intolerance to at least a
Yes
No
3-month trial with at least two of the following? (check all that apply):
Topical steroids available by prescription only;
(list drug[s]) _________________________________________________________________
Topical nonsteroids available by prescription only;
(list drug[s]) _________________________________________________________________
Methotrexate;
Retinoids (e.g., Soriatane);
(list drug[s]) ________________________________________________________________
Cyclosporine (e.g., Neoral, Gengraf);
(list drug[s]) ________________________________________________________________
For psoriatic arthritis only:
a.
Does the patient have a documented history of failure, contraindication, or intolerance to at least a
3-month trial of any disease-modifying antirheumatic drug (DMARD) such as, but not limited to,
Yes
No
sulfasalazine, azathioprine, hydroxychloroquine, cyclosporine, methotrexate, or anti-tumor necrosis factor
agents?
If yes, list drug(s) ___________________________________________________________________
3)
Prescription Information:
Quantity ________________________________________
Refill x ____________________ month(s)
Instructions (include dose) __________________________
every _____________________ day(s)/ week(s)/ month(s)
Physician’s Signature: _________________________________________________________________________________
Please fax this completed form to 215-761-9580.
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and
with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
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