5/2/2017 Prior Authorization Form INTOTAL HEALTH PLAN (SPC) Multiple Sclerosis MMT SGM This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-866-249-6155. Please contact CVS/Caremark at 1-866-814-5506 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Multiple Sclerosis MMT SGM. Drug Name (specify drug) Quantity Frequency Strength Route of Administration Expected Length of Therapy Patient Information Patient Name: Patient ID: Patient Group.: Patient DOB: Patient Phone: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: ICD Code: Comments: Please circle the appropriate answer for each question. 1. What drug is being prescribed? Ampyra Aubagio Avonex Betaseron Copaxone Extavia Gilenya Lemtrada Plegridy Rebif Tecfidera Tysabri
Glatopa Zinbryta 2. Betaseron, and Plegridy are the non-preferred products for this patient's health plan. Is the prescriber willing to switch to one of the following drugs? Yes, to Avonex (preferred products) Yes, to Extavia (preferred products) Yes, to Rebif (preferred products) Yes, to Gilenya Yes, to Copaxone Yes, to Aubagio Yes, to Ampyra Yes, to Tecfidera Yes, to Lemtrada Yes, Tysabri Yes, Glatopa, prescriber would like to continue to request Betaseron or Plegridy 3. Is the patient currently receiving the requested product through insurance coverage? te: If the patient is receiving the product through samples or a manufacturer s patient assistance program, please answer. Internal CRU te: Please review the past 120 days of the patient s claim history to confirm at least 28-day supply if Yes. 4. Is the request for Betaseron? 5. Extavia is the Preferred Formulary interferon beta-1b Product for this patient s plan. Can the patient be switched to Extavia? te: Extavia and Betaseron are the exact same products with different labels and brand names, which are made in the same manufacturing facility. 6. Avonex and Rebif are the other Preferred Formulary interferon beta Products for this patient s plan. Can the patient be switched to Avonex or Rebif? Yes, Avonex Yes, Rebif, prescriber would like to continue to request Betaseron 7. Is there a clinical reason that the patient must use Betaseron over Extavia? ACTION REQUIRED: If Yes, attach supporting clinical documents. 8. Avonex, Extavia, and Rebif are the Preferred Formulary interferon beta Products for this patient s plan. Can the patient be switched to one of these preferred products? Yes, Avonex Yes, Extavia Yes, Rebif, prescriber would like to continue to request Plegridy 9. Has the patient tried and had an inadequate response to at least one
of the Preferred Formulary interferon beta Products (i.e., Avonex, Extavia, Rebif)? Yes - Indicate the trial duration of Preferred Formulary interferon beta Product 10. Has the patient tried and was intolerant to or had a confirmed adverse event with at least one of the Preferred Formulary interferon beta Products (i.e., Avonex, Extavia, Rebif)? Yes - Indicate intolerance/adverse event(s) to the Preferred Formulary interferon beta Product 11. Does the patient have a contraindication to any of the Preferred Formulary interferon beta Products (i.e., Avonex, Extavia, Rebif) or any of their components? Yes - Indicate contraindication to the Preferred Formulary interferon beta Product(s) 12. Which drug is being prescribed? Betaseron Plegridy 13. Does the patient have a diagnosis of multiple sclerosis? 14. Is this request for continuation of therapy with Ampyra? 15. Is the patient receiving Ampyra through samples or a manufacturer s patient assistance program? 16. Has the patient experienced improvement in walking speed or another objective measure of walking ability since starting Ampyra therapy? 17. Prior to initiation of Ampyra therapy, does/did the patient have sustained walking impairment? 18. What is the diagnosis? 19. What is the diagnosis? (MS) 20. What is the diagnosis? (MS) 21. What is the diagnosis? (MS)
22. What is the diagnosis? (MS) 23. What is the diagnosis? 24. What is the diagnosis? ne of the above/ 25. How many courses of Lemtrada treatment has the patient received over his/her lifetime? previous courses (0 dose) One course (5 doses) Two courses or more (8 doses or more) 26. Has the patient had an inadequate response to two or more drugs indicated for multiple sclerosis? 27. What is the diagnosis? 28. What is the diagnosis? (MS) 29. What is the diagnosis? 30. What is the diagnosis? Crohn s disease 31. What is the diagnosis? (MS)
32. What is the diagnosis? Relapsing form multiple sclerosis (MS) 33. Has the patient had an inadequate response to two or more drugs indicated for multiple sclerosis? I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature and Date