Medicare First Blue Cross Blue Shield Prior Authorization/prescription Form - Arthritis

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ARTHRITIS ONLY / Cimzia, Enbrel, Humira, Orencia SQ, Simponi, Xeljanz

Medi-CareFirst BlueCross BlueShield Prior Authorization/Prescription Form

Please fax form to 1.877.800.4791 with a copy of member insurance ID card. For questions, please call 1.888.OncoSRx (662.6779).

Patient Information

Last Name:

First Name:

Home Phone Number: (

)

Work Phone Number: (

)

Home Address:

City:

State:

Zip:

Date of Birth:

❏

Allergies:

NKA

Other (List):

Insurance ID #:

Group #:

Physician Information

MD Name:

MD DEA #:

NPI #:

Address:

City:

State:

Zip:

Office Contact Name:

Phone Number: (

)

Fax Number: (

)

Primary Diagnosis

Primary ICD9 (Code):

Primary Diagnosis (In Words):

Select the medication and diagnosis:

Moderate to Severe Rheumatoid Arthritis

Psoriatic Arthritis

Ankylosing Spondylitis

Moderate to Severe Juvenile Idiopathic Arthritis

Cimzia

n/a

❏

Enbrel

❏

Humira

❏

Kineret

❏

n/a

Orencia SQ

❏

n/a

Simponi

❏

n/a

Xeljanz

❏

n/a

Clinical Information

❏

1. Is the patient naive to therapy or continuing therapy?

Naive

Continuing

If continuing, how long has the patient been on this medication?

❏

2. Has a dermatologist/rheumatologist recommended or requested therapy?

Yes

3. Has the patient failed or had an inadequate response to the trial of at least one or more disease-modifying antirheumatic drugs (DMARDS)? (eg, methotrexate, Imuran,

❏

Ridaura, Plaquenil, Cuprimine, Azulfidine, Arava)

Yes

❏

4. Is the patient receiving a tumor necrosis factor (TNF)-blocking agent?

Yes

❏

5. Will the TNF-blocking agent be discontinued?

Yes

❏

6. Is the patient currently taking methotrexate?

Yes