Carefirst Prior Authorization Request - Enbrel Page 2
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2Section B: Juvenile Idiopathic Arthritis
15. Is the patient currently receiving Enbrel for JIA? If yes, no further questions
Yes
No
16. Does the patient have active systemic JIA?
Yes
No
17. Has the patient tried and had an inadequate response to methotrexate? If yes, no further questions
Yes
No
18. Does the patient have intolerance or a contraindication to methotrexate?
Yes
No
Section C: Psoriasis
19. Is the patient currently on biologic therapy for psoriasis? If yes, no further questions
q Yes
No
Patient may be continuing treatment with the same biologic agent or is switching from one biologic agent to another
20. What is the percentage of body surface area (BSA) affected? (1% BSA = palm of hand) _____________ %
21. If less than 5% of BSA affected, does the patient’s psoriasis affect crucial body areas (hands, feet, face, neck, scalp, groin,
intertriginous areas)?
Yes
No
N/A, BSA affected is at least 5%
22. Has the patient tried and had an insufficient response to either phototherapy or traditional systemic therapy?
Yes
No If no, skip to #24
If Yes, document previous therapies that the patient has tried or had insufficient response to:
Phototherapy
Methotrexate
Cyclosporin
Acitretin
Other __________________________________
23. Has dose been optimized without adequate response?
Yes
No No further questions
24. Is there a clinical reason to avoid these therapies (phototherapy/conventional systemic therapy) as initial treatments?
Yes
No If yes, document the reason:
________________________________________________________
Section D: Ankylosing Spondylitis / Axial Spondyloarthritis
25. Is the patient currently receiving Enbrel for ankylosing spondylitis / axial spondyloarthritis?
Yes
No If yes, no further questions
26. Has the patient tried and had an inadequate response to at least 2 nonsteroidal anti-inflammatory drugs (NSAIDs)?
Yes
No If yes, no further questions
27. Does the patient have intolerance or a contraindication to NSAIDs?
Yes
No
If yes, document the intolerance or contraindication:
_________________________________________________
I attest that this information is accurate and true, and that documentation supporting this information is available for review
if requested by CVS/caremark or the benefit plan sponsor.
X____________________________________________________________________________________________
Prescriber or Authorized Signature
Date: (mm/dd/yy)
Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended recipient you
hereby are advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received the fax in error, please immediately notify the sender by
telephone and destroy the original fax message. Enbrel SGM – 3/2014
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