First Name. Specialty: Fax. First Name DOB: Duration:

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Clare Russell
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1 Prescriber Information Last ame: First ame DEA/PI: Specialty: Phone - - Fax - - Member Information Last ame: First ame Member ID umber DOB: - - Medication Information: Drug ame and Strength: Diagnosis: Quantity and Dosing: Duration: When advised below, please include all requested fax documentation (lab results, etc.) when submitting this Prior Authorization fax form; not submitting requested documentation could delay the clinical review process. Humira Prior Authorization Form Initial Therapy ou must answer ALL of the following questions 1. Will Humira be used in combination with another biologic response modifier (such as Kineret (anakinra), Rituxan (rituximab), Remicade (infliximab), Orencia (abatacept), Cimzia (certolizumab pegol), Enbrel (etanercept), Simponi (golimumab), Actemra (tocilizumab) or Xeljanz (tofacitinib))? 2. What is the patient s diagnosis? (Please Circle) Rheumatoid arthritis Crohn s disease Psoriatic arthritis Ankylosing spondylitis Juvenile idiopathic arthritis (JIA) Plaque psoriasis Ulcerative colitis Pyoderma gangrenosum Hidradenitis suppurativa on-infectious uveitis Other: Rheumatoid arthritis (RA) 3. Is the patient 18 years of age or older? Page 1 of 6

2 4. Is the medication prescribed by a rheumatologist? 5. Has the patient had a trial with methotrexate (or another oral disease modifying anti-rheumatic agent (DMARD) such as azathioprine (Imuran), auranofin (Ridaura), hydroxychloroquine (Plaquenil), penicillamine (Cuprimine), sulfasalazine (Azulfidine), leflunomide (Arava))? Must submit chart documentation on therapies patient has tried. 6. Does the patient have chronic liver disease (such as chronic hepatitis, fatty liver, nonalcoholic steatohepatitis/ash, elevated liver enzymes)? 7. Is the patient unable to take a non-biologic DMARD because they are a male of fatherhood potential or a female of childbearing potential? If no, please provide rationale explaining why the patient cannot take the prerequisite DMARDs: Juvenile idiopathic arthritis (JIA) 3. Is the medication prescribed by a rheumatologist? 4. Is the patient 2 years of age or older? 5. Has the patient had a trial and inadequate response to therapy with oral disease modifying antirheumatic agents (DMARDs, e.g., methotrexate, azathioprine (Imuran), auranofin (Ridaura), hydroxychloroquine (Plaquenil), penicillamine (Cuprimine), sulfasalazine (Azulfidine), leflunomide (Arava))? Must submit chart documentation on therapies patient has tried. 6. Does the patient have chronic liver disease (such as chronic hepatitis, fatty liver, nonalcoholic steatohepatitis/ash, or elevated liver enzymes)? 7. Is there clinical rationale explaining why the patient cannot try a DMARD? Psoriatic arthritis (PsA) 3. Is the medication prescribed by a rheumatologist or dermatologist? 4. Is the patient 18 years of age or older? 5. Has the patient had a trial and inadequate response to therapy with oral disease modifying antirheumatic agents (DMARDs, e.g., methotrexate, azathioprine (Imuran), auranofin (Ridaura), hydroxychloroquine (Plaquenil), penicillamine (Cuprimine), sulfasalazine (Azulfidine), leflunomide (Arava))? Must submit chart documentation on therapies patient has tried. 6. Does the patient have chronic liver disease (such as chronic hepatitis, fatty liver, nonalcoholic steatohepatitis/ash, or elevated liver enzymes)? 7. Is there clinical rationale explaining why the patient cannot try a DMARD? Ankylosing Spondylitis 3. Is the patient 18 years of age or older? 4. Is the medication prescribed by a rheumatologist? 5. Has the patient had a trial and inadequate response to at least TWO non-steroidal anti-inflammatory agents (SAIDs)? Must submit which 2 SAIDs. 6. Are non-steroidal anti-inflammatory agents (SAIDs) contraindicated in this patient? Must provide rationale. Page 2 of 6

3 Plaque Psoriasis 3. Is the patient 18 years of age or older? 4. Is the medication prescribed by a rheumatologist or dermatologist? 5. Does the patient have plaques covering greater than or equal to 3% of their body surface area (BSA) or less than 3% of BSA, but with involvement of palms, soles, head and neck, or genitalia which causes disruption of normal activities? 6. Has the patient tried and had an inadequate response to therapy with at least one of the following: methotrexate, cyclosporine, acitretin and/or photo Must submit what therapies have been tried. 7. Is there clinical rationale explaining why the patient cannot try any of the following: methotrexate, cyclosporine, acitretin or photo Crohn s Disease 3. Is the medication prescribed by a gastroenterologist or rheumatologist? 4. Has the patient tried and had an inadequate response to glucocorticoid therapy, methotrexate, azathioprine, 6-mercaptopurine or 5-ASA/mesalamine? If yes, please provide supporting chart notes. 5. Is there clinical rationale explaining why the patient cannot try glucocorticoid therapy, methotrexate, azathioprine, 6-mercaptopurine or 5-ASA/mesalamine? Ulcerative colitis 3. Is the medication prescribed by a gastroenterologist or rheumatologist? 4. Has the patient tried and had an inadequate response to at least one of the following: corticosteroids, azathioprine, and/or 6-mercaptopurine Please provide supporting chart notes. 5. Is there clinical rationale explaining why the patient cannot try any of the following: corticosteroids, azathioprine, or 6-mercaptopurine? Pyoderma gangrenosum 3. Is the medication prescribed by a rheumatologist or dermatologist? 4. Has the patient tried and had an inadequate response to glucocorticoid If yes, please provide supporting chart notes. Page 3 of 6

4 5. Has the patient tried and had an inadequate response to at least one of the following systemic therapies? (Please Circle) Cyclosporine Mycophenolate Azathioprine Dapsone Tacrolimus Cyclophosphamide Chlorambucil Thalidomide icotine Intravenous immune globulin Hyperbaric oxygen If yes, please submit supporting chart notes. 6. Is there clinical rationale explaining why the patient cannot try corticosteroids and one additional systemic therapy (such as cyclosporine, mycophenolate, dapsone, azathioprine, etc.)? Hidradenitis suppurativa 3. Is the medication prescribed by a dermatologist? 4. Is the medication being used prior to surgery? on-infectious uveitis 3. Is the medication being prescribed by an ophthalmologist or a rheumatologist? 4. Is the patient 18 years of age or older? 5. Does the patient have isolated anterior uveitis? Renewal Therapy ou must answer ALL of the following questions 1. What is the patient s diagnosis? (Please Circle) Rheumatoid arthritis Crohn s disease Psoriatic arthritis Ankylosing spondylitis Juvenile idiopathic arthritis (JIA) Plaque psoriasis Ulcerative colitis Hidradenitis suppurativa Pyoderma gangrenosum on-infectious uveitis Other: Rheumatoid arthritis (RA) 2. Is the patient continuing to have a positive clinical response and remission of disease with Humira 3. Is the medication prescribed by a rheumatologist? Page 4 of 6

5 Crohn s Disease 2. Is the patient continuing to have a positive clinical response and remission of disease with Humira 3. Is the medication prescribed by a gastroenterologist or rheumatologist? Psoriatic arthritis (PsA) 2. Is the patient continuing to have a positive clinical response and remission of disease with Humira 3. Is the medication prescribed by a rheumatologist or dermatologist? Ankylosing Spondylitis 2. Is the patient continuing to have a positive clinical response and remission of disease with Humira 3. Is the medication prescribed by a rheumatologist? Juvenile idiopathic arthritis (JIA) 2. Is the patient continuing to have a positive clinical response and remission of disease with Humira 3. Is the medication prescribed by a rheumatologist? Plaque Psoriasis 2. Is the patient continuing to have a positive clinical response and remission of disease with Humira 3. Is the medication prescribed by a rheumatologist or dermatologist? Ulcerative colitis 2. Is the patient continuing to have a positive clinical response and remission of disease with Humira 3. Is the medication prescribed by a gastroenterologist or rheumatologist? Hidradenitis suppurativa 2. Is the patient continuing to have a positive clinical response and remission of disease with Humira 3. Is the medication prescribed by a dermatologist? Pyoderma gangrenosum 2. Is the patient continuing to have a positive clinical response and remission of disease with Humira Page 5 of 6

6 on-infectious uveitis 2. Has the patient s response been evaluated at a recent office visit (i.e., occurring after previous date of approval)? Please provide supporting progress notes/chart notes from the patient s ophthalmologist or rheumatologist. 3. Has the patient experienced a positive response to 4. Is the medication prescribed by an ophthalmologist or rheumatologist? Please note, not all drugs/diagnoses are covered on all plans. Comments: Information given on this form is accurate as of this date. Caterpillar Prior Authorization forms are located at on the For Providers tab. Print a new form for each request as forms are updated periodically. Prescriber or Authorized Signature Date Authorized Medical Staff ame/title Attention Healthcare Provider: If you would like to discuss this request with a medical professional, please contact the Prior Authorization Department at I understand that use or disclosure by OptumRx of individually identifiable health information, whether furnished by me or obtained by another source such as medical providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996). Page 6 of 6

Immune Modulating Drugs Prior Authorization Request Form

Immune Modulating Drugs Prior Authorization Request Form Patient: HPHC member ID #: Requesting provider: Phone: Servicing provider: Diagnosis: Contact for questions (name and phone #): Projected start and end date for requested Requesting provider NPI: Fax: