CONTAINS CONFIDENTIAL PATIENT INFORMATION
Actemra (tocilizumab)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: _______________________________
Prescribing Physician: _________________________
Patient ID #:
_______________________________
Physician Address:
_________________________
Patient DOB: _______________________________
Physician Phone #:
_________________________
Date of Rx:
Physician Fax #:
_________________________
Patient Phone #. _____________________________
Physician Specialty:
_________________________
Patient Email Address: ________________________
Physician DEA:
_________________________
Physician NPI #:
_________________________
_______________________________
3. MEDICATION
4. STRENGTH
Physician Email Address: ______________________
5. DIRECTIONS
6. QUANTITY
Actemra (tocilizumab)
_______________
__________________________
Specify: _________________
7. DIAGNOSIS: ___________________________________________________________________________________
8. APPROVAL CRITERIA:
CHECK ALL BOXES THAT APPLY
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
A RESPONSE IS REQUIRED FOR EACH OF THE FOLLOWING:
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Has the patient had Tuberculosis, invasive fungal infection, or other active serious infections, or a
history of recurrent infections?
Has the patient had a tuberculin skin test (TST), or a Centers for Disease Control and Prevention
(CDC)-recommended equivalent, to evaluate for latent Tuberculosis prior to initiating Actemra
(tocilizumab)?
Will the patient be using Actemra (tocilizumab) in combination with other biologic disease
modifying anti-rheumatic drugs (DMARDs) such as anti-CD20 monoclonal antibodies, IL-1R
antagonists, Janus kinas inhibitors (for example, tofacitinib citrate), selective co-stimulation
modulators, or TNF antagonists?
3
Does the patient have an absolute neutrophil count (ANC) less than 2000/mm , platelet count less
3
than 100,000/mm , or ALT or AST above 1.5 times the upper limit of normal (ULN)?
Rheumatoid Arthritis (RA):
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ Yes
□ No
□ Yes □ No
□ Yes
□ No
Is the patient 18 years of age or older?
Does the patient have moderately to severely active rheumatoid arthritis?
Is Actemra (tocilizumab) being used for any of the following reasons: to reduce signs or symptoms,
to induce or maintain clinical response, to inhibit the progression of structural damage, or to improve
physical function?
Has the patient had an inadequate response to a trial of 1 or more disease modifying anti-rheumatic
drugs (DMARDs) (for example, methotrexate [MTX]) or a tumor necrosis factor [TNF] antagonist
drug
Will the patient be using Actemra (tocilizumab) alone or in combination with MTX or with other nonbiologic DMARDs?
Has the patient had an inadequate response to 2 preferred biologic therapies in the previous 180
days? (please indicate):
□ Enbrel (etanercept) □ Humira (adalimumab) □ Remicade (infliximab) □ Simponi (golimumab)
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Actemra NTL PAB Fax Form 10.12.15.doc
CONTAINS CONFIDENTIAL PATIENT INFORMATION
Actemra (tocilizumab)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
Patient Name: ___________________________________
Patient ID#: __________________________________
Systemic Juvenile Idiopathic Arthritis (SJIA):
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ Yes
□ No
Is the patient 2 years of age or older?
Does the patient have active Systemic Juvenile Idiopathic Arthritis (SJIA)?
Is Actemra (tocilizumab) being used to reduce signs or symptoms, or to induce or maintain clinical
response?
Has the patient failed to respond to, is intolerant of, or has a medical contraindication to 1 or more
corticosteroids or non-steroidal anti-inflammatory drugs (NSAIDs)?
Polyarticular Juvenile Idiopathic Arthritis (PJIA):
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ Yes
□ No
Is the patient 2 years of age or older?
Does the patient have active polyarticular juvenile idiopathic arthritis (PJIA)?
Is Actemra (tocilizumab) being used to reduce signs or symptoms, or to induce or maintain clinical
response?
Has the patient failed to respond to, is intolerant of, or has a medical contraindication to 1 or more
non-biologic DMARDs (such as MTX)?
9. PHYSICIAN SIGNATURE
____________________________________________________________
__________________________________________
Prescriber or Authorized Signature
Date
Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what
medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting
provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.
Note: Payment is subject to member eligibility. Authorization does not guarantee payment.
The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only
for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other
party unless required to do so by law or regulation.
If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of
these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or
destruction of these documents.
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Actemra NTL PAB Fax Form 10.12.15.doc