Form F-11304 - Prior Authorization/preferred Drug List (Pa/pdl) For Cytokine Page 2

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PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL ADHESION MOLECULE
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(CAM) ANTAGONIST DRUGS FOR ANKYLOSING SPONDYLITIS
F-11304 (01/2017)
SECTION III – CLINICAL INFORMATION FOR ANKYLOSING SPONDYLITIS (Continued)
16. Is the member currently using the requested cytokine and CAM antagonist drug?
Yes
No
If yes, indicate the approximate date therapy was started.
17. Check the boxes next to the drugs below that the member has taken for at least three consecutive months and experienced an
unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction; check “none” if appropriate.
1.  leflunomide
Dose
Dates Taken
Reason for Discontinuation
2.  methotrexate
Dose
Dates Taken
Reason for Discontinuation
3.  NSAID or COX-2 Dose
Dates Taken
Reason for Discontinuation
4.  sulfasalazine
Dose
Dates Taken
Reason for Discontinuation
5.  None
If none, indicate the reason the member is unable to use the drugs listed above.
Note: If none, a copy of the member’s medical records must be submitted with the PA request to support the
condition being treated, details regarding previous medication use and outline the member’s current treatment
plan.
18. Has the member attempted other drug therapies for ankylosing spondylitis (e.g., glucocorticoids
or IV immunomodulators such as infliximab)?
Yes
No
If yes, indicate the drug names, dose, specific details about the treatment response, and the approximate dates each drug was
taken in the space provided. If additional space is needed, continue documentation in Section VI of this form.
Continued

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