Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
Multiple Sclerosis Medication
Precertification Request
Page 1 of 2
(All fields must be completed and legible for Precertification Review.)
Please indicate:
Start of treatment: Start date
/
/
Continuation of therapy: Date of last treatment
/
For Medicare Advantage Part B:
FAX:
1-844-268-7263
/
Precertification Requested By:
Phone:
Fax:
A. PATIENT INFORMATION
First Name:
Last Name:
Address:
City:
Home Phone:
State:
Work Phone:
DOB:
Allergies:
Current Weight:
lbs or
ZIP:
Cell Phone:
E-mail:
kgs
Height:
inches or
cms
B. INSURANCE INFORMATION
Aetna Member ID #:
Group #:
Insured:
Medicare:
Yes
Does patient have other coverage?
If yes, provide ID#:
Insured:
No
If yes, provide ID #:
Medicaid:
Yes
Yes
No
Carrier Name:
No
If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name:
Last Name:
Address:
City:
Phone:
Fax:
(Check One):
State:
St Lic #:
Provider E-mail:
NPI #:
DEA #:
Neurologist
Primary Care
D.O.
N.P.
P.A.
ZIP:
UPIN:
Office Contact Name:
Specialty (Check one):
M.D.
Phone:
Other:
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
Place of Administration:
Self-administered
Physician’s Office
Outpatient Infusion Center
Phone:
Center Name:
Home Infusion Center
Phone:
Agency Name:
Administration code(s) (CPT):
Dispensing Provider/Pharmacy: Patient Selected choice
Physician’s Office
Retail Pharmacy
Specialty Pharmacy
Mail Order
Other:
Name:
Phone:
Fax:
TIN:
PIN:
E. PRODUCT INFORMATION
Request is for:
Dose:
Aubagio
Plegridy
Avonex
Rebif
Frequency:
Betaseron
Tecfidera
Copaxone
Tysabri
Extavia
Gilenya
Glatopa
Lemtrada
(Failure to indicate dose and frequency may extend review time)
F. DIAGNOSIS INFORMATION – Please indicate primary ICD Code and specify any other where applicable.
Primary ICD Code:
Secondary ICD Code:
Other ICD Code:
G. CLINICAL INFORMATION – Required clinical information must be completed in its entirety for all precertification requests.
For All Requests
Yes
No Does the patient have a documented diagnosis of relapsing remitting multiple sclerosis?
Yes
No Has the patient experienced signs and symptoms of Clinically Isolated Syndrome suggestive of MS that has been
confirmed with magnetic resonance imaging (MRI)?
Yes
No Will the drug requested be used as monotherapy?
Yes
No Has the patient received samples of any of the MS products?
If yes, please indicate which products:
______________________________________
(Sampling of any the Multiple Sclerosis products does not guarantee coverage under the provisions of the pharmacy benefit)
For COPAXONE:
Yes
No Is the request for 20 mg of Copaxone?
If yes,
Yes
No Does the patient have a contraindication, intolerance or allergy to Glatopa?
Yes
No Does the patient have a documented failure of an adequate trial of Glatopa?
If yes, please indicate which of the following describe the evidence of treatment failure:
Yes
No
The patient has increasing relapses (defined as two or more relapses in a year, or one severe relapse
associated with either poor recovery or MRI lesion progression)
Yes
No
The patient has lesion progression by MRI (increased number or volume of gadolinium-enhancing lesions,
T2 hyperintense lesions or T1 hypointense lesions)
Yes
No
The patient has worsening disability (sustained worsening of Expanded Disability Status Scale (EDSS)
score or neurological examination findings)
For GILENYA:
Yes
No Does the patient have a documented recent (within 6 months) complete blood count (CBC)?
Yes
No Does the patient have a documented recent (within 6 months) liver transaminase and bilirubin?
Yes
No Will the patient have an EKG prior to the first dose and at the end of the observation period?
Continued on next page
GR-68750 (12-15)
Multiple Sclerosis Medication
Precertification Request
Page 2 of 2
(All fields must be completed and legible for Precertification Review.)
Patient First Name
Patient Last Name
Patient Phone
Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
For Medicare Advantage Part B:
FAX:
1-844-268-7263
Patient DOB
G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests.
For GILENYA – also complete the following:
Yes
No Has the patient had a recent (within the last 6 months) occurrence of myocardial infarction, unstable angina, stroke,
transient ischemic attack, decompensated heart failure requiring hospitalization, or Class III/IV heart failure?
Yes
No Does the patient have history or presence of Mobitz Type II 2nd degree or 3rd degree AV block or sick sinus syndrome?
Yes
No Does the patient have a pacemaker?
Yes
No Does the patient have a baseline QTc interval ≥500 ms (as measured on most recent EKG)?
Yes
No Is the patient on any Class Ia or Class III anti-arrhythmic drugs?
Yes
No Does the patient have a documented baseline ophthalmologic examination?
Yes
No Does the patient have a documented history of chicken pox or administration of the varicella zoster vaccine (VZV)?
Yes
No
If female, does the patient have a documented negative pregnancy test?
For AUBAGIO, AVONEX, BETASERON, EXTAVIA, LEMTRADA, PLEGRIDY, TECFIDERA, & TYSABRI – also complete the following:
Yes
No Has the patient received samples for the drug being requested? (Sampling of medication does not guarantee coverage under the provisions of
the pharmacy benefit)
Yes
No Does the patient have a contraindication, intolerance or allergy to Copaxone or Glatopa?
Yes
No Does the patient have a documented failure of an adequate trial of Copaxone or Glatopa?
If yes, please indicate which of the following describe the evidence of treatment failure:
The patient has increasing relapses (defined as two or more relapses in a year, or one severe relapse associated with either poor recovery or
MRI lesion progression)
The patient has lesion progression by MRI (increased number or volume of gadolinium-enhancing lesions, T2 hyperintense lesions or T1
hypointense lesions)
The patient has worsening disability (sustained worsening of Expanded Disability Status Scale (EDSS) score or neurological examination
findings)
Yes
No Does the patient have a contraindication, intolerance or allergy to Gilenya?
Yes
No Does the patient have a documented failure of an adequate trial of Gilenya?
If yes, please indicate which of the following describe the evidence of treatment failure:
The patient has increasing relapses (defined as two or more relapses in a year, or one severe relapse associated with either poor recovery or
MRI lesion progression)
The patient has lesion progression by MRI (increased number or volume of gadolinium-enhancing lesions, T2 hyperintense lesions or T1
hypointense lesions)
The patient has worsening disability (sustained worsening of Expanded Disability Status Scale (EDSS) score or neurological examination
findings)
Yes
No Does the patient have a contraindication, intolerance or allergy to Rebif?
Yes
No Does the patient have a documented failure of an adequate trial of Rebif?
If yes, please indicate which of the following describe the evidence of treatment failure:
The patient has increasing relapses (defined as two or more relapses in a year, or one severe relapse associated with either poor recovery or
MRI lesion progression)
The patient has lesion progression by MRI (increased number or volume of gadolinium-enhancing lesions, T2 hyperintense lesions or T1
hypointense lesions)
The patient has worsening disability (sustained worsening of Expanded Disability Status Scale (EDSS) score or neurological examination
findings)
For AUBAGIO – also complete the following:
Yes
No Does the patient have a documented (within 6 months) complete blood count (CBC)?
Yes
No Does the patient have a documented (within 6 months) liver transaminase and bilirubin?
Yes
No Does the patient have a documented (within 6 months) Tuberculin skin test to check latent Tuberculosis?
Yes
No Has/will the patient’s blood pressure be monitored at initiation and during treatment?
Yes
No If female, does the patient have a documented negative pregnancy test?
Yes
No If female, is there confirmation that reliable contraception will be used during treatment with Aubagio?
For LEMTRADA – also complete the following:
Yes
No Is the patient HIV negative?
For Tecfidera – also complete the following:
Yes
No Does the patient have a documented recent (within 6 months) complete blood count (CBC)?
For TYSABRI – also complete the following:
Yes
No Does the patient have a documented anti-JCV antibody test with ELISA prior to initiating treatment?
Yes
No Has the patient had a documented anti-JCV antibody test with ELISA within the last 12 months?
If yes, please indicate the date of testing:
/
/
H. ACKNOWLEDGEMENT
Request Completed By (Signature Required):
Date:
/
/
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or
deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading,
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
The plan may request additional information or clarification, if needed, to evaluate requests.
GR-68750 (12-15)