Form Gr-68850 - Humira Precertification Request Form Page 2

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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 2 of 2

(Please complete all fields and return both pages for precertification review)

Patient First Name

Patient Last Name

Patient Phone

Patient DOB

G. CLINICAL INFORMATION Section 2 - Required clinical information must be completed in its entirety for all precertification requests.

For Plaque Psoriasis

Yes

Does the patient have moderate to severe chronic plaque psoriasis?

Yes

Is the patient a candidate for systemic therapy or phototherapy?

Yes

Does the plaque psoriasis affect 10% or more of the body surface area?

Yes

Does the patient have a Psoriasis Area and Severity Index (PASI) score 10 or more?

Yes

Has the patient failed to adequately respond to or was the patient intolerant to a 3 month trial to any of the following phototherapies:

Psoralens (methoxsalen, trioxsalen) with UVA light (PUVA)

If yes, please check all that apply:

UVB with coal tar or dithranol

UVB (standard or narrow-band)

Contraindicated: Please explain:

For continuation of therapy:

Has the patient had significant improvement or adequate response after 12 weeks of Adalimumab (Humira) treatment?

Yes

For Rheumatoid Arthritis

Yes

Does the patient have moderately to severely active rheumatoid arthritis?

For Polyarticular Juvenile Idiopathic Arthritis

Yes

Does the patient have moderately to severely active polyarticular juvenile idiopathic arthritis (juvenile rheumatoid arthritis)?

For Ankylosing Spondylitis

Yes

Does the patient have active ankylosing spondylitis?

Yes

Has the patient had an inadequate response to non-steriodal anti-inflamatory drugs (NSAIDs)?

If yes, check ALL that apply:

ibuprofen

meloxicam

naproxen

Other:

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-68850 (5-13)