Form Gr-68850 - Humira Precertification Request Form
Download a blank fillable Form Gr-68850 - Humira Precertification Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Gr-68850 - Humira Precertification Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2®
Aetna Precertification Notification
Adalimumab (Humira
) Injectable Medication
503 Sunport Lane, Orlando, FL 32809
Precertification Request
Phone:
1-866-503-0857
FAX:
1-888-267-3277
Page 1 of 2
(Please complete all fields and return both pages for precertification review)
Please indicate:
Start of treatment: Start Date:
/
/
Continuation of therapy: Date of last treatment:
/
/
Precertification Requested By:
Phone:
Fax:
A. PATIENT INFORMATION
First Name:
Last Name:
DOB:
Address:
City:
State:
ZIP:
Home Phone:
Work Phone:
Cell Phone:
Email:
Current Weight:
lbs or
kgs
Height:
inches or
cms
Allergies:
B. INSURANCE INFORMATION
Aetna Member ID #:
Does patient have other coverage?
Yes
No
If yes, provide ID#:
Carrier Name:
Group #:
Insured:
Insured:
Medicare:
Yes
No If yes, provide ID #:
Medicaid:
Yes
No If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name:
Last Name:
(Circle one): M.D. D.O. N.P. P.A.
Address:
City:
State:
ZIP:
Phone:
Fax:
St Lic #:
NPI #:
DEA #:
UPIN:
Provider Email:
Office Contact Name:
Phone:
Specialty (Check one):
Rheumatologist
Dermatologist
Gastroenterologist
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
Specialty Pharmacy
Mail Order
Outpatient Infusion Center
Phone:
Other:
Center Name:
Name:
Home Infusion Center
Phone:
Agency Name:
Phone:
Fax:
TIN:
PIN:
Administration code(s) (CPT):
E. PRODUCT INFORMATION
Request is for Humira:
Dose:
Frequency:
F. DIAGNOSIS INFORMATION - Please indicate primary ICD-9 code and specify any other where applicable.
Primary ICD-9:
696.1 Other psoriasis
720.0 Ankylosing spondylitis
Regional enteritis (550.0-555.9)
Rheumatoid Arthritis (714.0 - 714.2)
Secondary ICD-9:
Ulcerative colitis (556 - 556.9)
Juvenile rheumatoid arthritis (714.3 - 714.33)
Other:
696.0 Psoriatic arthritis
G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests.
For ALL requests
Yes
No
Will adalimumab (Humira) be used in combination with other tumor necrosis-factor blocking agents?
For Crohn’s Disease
Yes
No
Does the patient have active Crohn’s disease manifested by:
Check all that apply:
abdominal pain
arthritis
bleeding
diarrhea
internal fistulae
intestinal obstruction
megacolon
perianal disease
spondylitis
weight loss
Yes
No
Has the Crohn’s disease remained active despite treatment with 6-mercaptopurine, azathioprine or corticosteroids?
Yes
No
Is this patient a child or adolescent with active Crohn’s disease that has not responded to infliximab (Remicade) or has developed infusion
reactions to infliximab (Remicade)?
For Ulcerative Colitis
Yes
No
Does the patient have moderate to severe ulcerative colitis?
Yes
No
Has the patient continued to respond to and remained tolerant to tumor necrosis factor blockers (TNF)?
Yes
No
Has the patient continued to show evidence of clinical remission by 8 weeks of therapy?
For Psoriatic Arthritis
Yes
No
Does the patient have moderately to severely active psoriatic arthritis?
Yes
No
Has the patient had an inadequate response to non-biologic disease-modifying anti-rheumatic drugs (DMARDs)?
If yes, check ALL that apply:
anti-malarials
cyclosporine
gold compounds
methotrexate
sulfasalazine
Other:
GR-68850 (5-13)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business