Mdwise Medication Request Form (Mrf) For Healthy Indiana Plan (Hip) And Hoosier Care Connect (Hcc) Page 3

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®
Stelara
(ustekinumab)
2.
Does the patient have a diagnosis of moderate to severe plaque psoriasis?
o Yes
o No
AND
Is this for initial therapy (i.e is patient naïve to this medication)?
o Yes
o No
If no, did the patient achieve or maintain clear or minimal disease or experience a decrease in PASI (Psoriasis Area and
Severity Index) of at least 50% or more?
o Yes
o No
Page | 3
AND
Does the plaque psoriasis involve at least 10% body surface area (BSA) or are there psoriatic lesions affecting the hands, feet,
or genital area?
o Yes
o No
AND
Has this medication been prescribed by or in consultation with a dermatologist?
o Yes
o No
AND
Has the patient tried or have a contraindication to at least ONE form of the following preferred therapies?
PUVA (Phototherapy Ultraviolet Light A)
o Yes
o No
UVB (Ultraviolet Light B)
o Yes
o No
If yes, please describe the response/reaction or CI to that treatment:
topical corticosteroids
o Yes
o No
____________________________________________________
acitretin
o Yes
o No
____________________________________________________
calcipotriene
o Yes
o No
____________________________________________________
methotrexate
o Yes
o No
____________________________________________________
cyclosporine
o Yes
o No
____________________________________________________
AND
®
®
Has the patient tried BOTH Cosentyx
and Otezla
?
o Yes
o No
If yes, describe response: ________________________________________________________________________
_____________________________________________________________________________________________
3.
Please attach additional information which may indicate why this specific medication is being requested for this patient.
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