Prior Authorization For Cytokine And Cell Adhesion Molecule Antagonist Drugs For Rheumatoid Arthritis And Polyarticular Juvenile Ra Form Page 2

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PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL ADHESION MOLECULE (CAM)
Page 2 of 3
ANTAGONIST DRUGS FOR RHEUMATOID ARTHRITIS (RA) AND POLYARTICULAR JUVENILE RA
F-11308 (12/12)
SECTION III — CLINICAL INFORMATION FOR RA AND POLYARTICULAR JUVENILE RA (Continued)
17. Has the member received two or more of the drugs listed below and taken each drug for
at least three consecutive months and experienced an unsatisfactory therapeutic response
or experienced a clinically significant adverse drug reaction?
Yes
No
If yes, check the boxes next to the drugs the member received. Indicate the dose of the drugs, specific details about the
unsatisfactory therapeutic responses or clinically significant adverse drug reactions, and the approximate dates the drugs were
taken in the space below.
1.  azathioprine
2.  cyclosporine
3.  hydroxychloroquine
4.  leflunomide
5.  methotrexate
6.  NSAIDs or COX-2
7.  oral corticosteroids
8.  penicillamine
9.  sulfasalazine
SECTION IIIA — ADDITIONAL CLINICAL INFORMATION FOR NON-PREFERRED CYTOKINE AND CAM ANTAGONIST DRUG
REQUESTS (Prior authorization requests for non-preferred cytokine and CAM antagonist drugs must be submitted on
paper.)
18. Has the member taken two preferred cytokine and CAM antagonist drugs for at least three
consecutive months and experienced an unsatisfactory therapeutic response or experienced
 No
a clinically significant adverse drug reaction?
Yes
If yes, indicate the two preferred cytokine and CAM antagonist drugs and doses, specific details about the unsatisfactory
therapeutic responses or clinically significant adverse drug reactions, and the approximate dates the preferred cytokine and CAM
antagonist drug was taken in the space provided.
1.
2.
SECTION IIIB — ADDITIONAL CLINICAL INFORMATION FOR SIMPONI REQUESTS
19. Will the member continue to take methotrexate in combination with Simponi?
Yes
No
SECTION IV — AUTHORIZED SIGNATURE
20. SIGNATURE — Prescriber
21. Date Signed
SECTION V — FOR PHARMACY PROVIDERS USING STAT-PA
22. National Drug Code (11 digits)
23. Days’ Supply Requested (Up to 365 Days)
24. NPI
25. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future or up to 14 days
in the past.)
Continued

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