Carefirst Prior Authorization Request - Enbrel
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2Enbrel® – Prior Authorization Request
Send completed form to: Case Review Unit CVS/caremark Specialty Programs Fax: 866-249-6155
CVS/caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain
medications in order for the drug to be covered. To make an appropriate determination, providing the most accurate diagnosis for the use of the prescribed
medication is necessary. Please respond below and fax this form to CVS/caremark toll-free at 866-249-6155. If you have questions regarding the prior
authorization, please contact CVS/caremark at 866-814-5506. For inquiries or questions related to the patient’s eligibility, drug copay or medication delivery;
®
please contact the Specialty Customer Care Team: CaremarkConnect
800-237-2767.
Patient Name:
Date:
Patient’s ID:
Patient’s Date of Birth:
Physician’s Name:
Specialty:
NPI#:
Physician Office Telephone:
Physician Office Fax:
1. What is the drug being prescribed?
Enbrel®
Other ________________________
2. What is the diagnosis?
Rheumatoid arthritis (RA)
Ankylosing spondylitis/axial spondyloarthritis
Juvenile idiopathic arthritis (JIA)
Reactive arthritis
Psoriasis
Hidradenitis suppurativa
Psoriatic arthritis
Other __________________________________________________
3. What is the ICD code? ________________
4.
Is the patient currently receiving treatment with a biologic agent or Xeljanz®?
Yes
No
5. Prior to initiating treatment with a biologic agent or Xeljanz®, has the patient been screened for latent tuberculosis (TB)
infection with either a TB skin test or an interferon gamma release assay (e.g., QFT-GIT, T-SPOT.TB)?
Yes
No
6. What was the latent TB test result?
Positive
Negative If negative, continue to diagnosis section
7. If positive, has active TB been ruled out?
Yes
No
8. Is the patient currently receiving or has completed treatment for latent TB?
Yes
No
Complete the following section based on patient's diagnosis
Section A: Rheumatoid Arthritis
9. Is the patient currently receiving Enbrel for RA?
Yes
No If no, skip to #11
10. Has the patient achieved low disease activity or improvement in the condition?
Yes
No No further questions
11. Has the patient received a prior biologic agent or Xeljanz® for RA? If yes, no further questions
Yes
No
12. Does the patient have severely active RA that warrants initial therapy with a TNF inhibitor?
If yes, no further questions
Yes
No
13. Did the patient fail to respond to an adequate trial of methotrexate (MTX)? If yes, no further questions
Yes
No
14. Was the patient unable to tolerate MTX or does the patient have a contraindication to MTX?
Yes
No
If yes, document the intolerance or contraindication: _________________________________________________
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association
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