State Sponsored Business, UniCare Health Plan of Kansas, Inc.
Remicade® (infliximab) Enrollment Form
Page 4 of 4
Fax completed form to: CuraScriptFax number: 1-866-545-0062 | Provider Services phone number: 1-888-662-0944
Part I Patient Information
Patient’s last name / First name / Middle initial
Address
City / State / ZIP code
Day phone number
( ) - / Night phone number
( ) - / Date of birth
/
Parent/Guardian / Allergies / Sex
M F
Primary insurance / Secondary insurance
Cardholder name (if not patient) / Cardholder name (if not patient)
Member ID and Group number / BIN# / Member ID and Group number / BIN#
Insurance phone number (+area code)
( ) - / Insurance phone number (+area code)
( ) -
Employer / Employer
Part II Physician Information (please supply copy of patient’s insurance card)
Prescriber’s name / Hospital/Clinic / Office contact name
Address
City / State / ZIP code
Phone number (+area code)
( ) - / Fax number (+area code)
( ) -
DEA number / NPI / UPIN
Part III Medical Criteria (double click on the fields below to fill in this form electronically)
MEDICAL CRITERIA
Primary Diagnosis (ICD9 Code): Secondary Diagnosis (ICD9 Code):
Prior Therapy:
Yes No Has patient received previous treatment? If yes, drug(s) used and dates of therapy:
Drug: Date: / / Duration:
Drug: Date: / / Duration:
Approval Criteria for Remicade:
Patient has none of the following concomitant conditions:
Yes No Patient has hypersensitivity to any murine proteins or other components of the product
Yes No Patient has moderate to severe (NYHA Class III/IV) Congestive Heart Failure (CHF)
Yes No Individuals with CHF who develop new symptoms or worsening symptoms of pre-existing CHF
Yes No Patient has Tuberculosis or other active infection
Yes No Patients has had a tuberculin skin test to rule out latent tuberculosis.
Yes No Patient has Multiple Sclerosis and other demyelinating diseases
Yes No Remicade will be used in combination with other tumor necrosis factor blocking agents or anakinra (Kineret)
Yes No Patient is currently receiving phototherapy, systemic psoriasis therapy (except for methotrexate, glucocorticoids, salicylates, non-steroidal anti-inflammatory drugs, or analgesics), immunosuppressive therapy, or Anakinra.
Yes No Patient is a pregnant women or nursing mother
Patient’s Last Name: First Name: DOB: / /
Part III Medical Criteria (continued)
Rheumatoid Arthritis (RA):
Yes No Patient has a diagnosis of moderately to severely active Rheu`matoid Arthritis
Yes No Patient is 18 years of age or older
Yes No Patient is currently on methotrexate (if patient is intolerant to methotrexate, in combination with another immunosuppressive agent that has also been demonstrated to prevent the development of human anti-chimeric antibodies [HACA], i.e. azathioprine, cyclosporine, or sulfasalazine)
Yes No Patient has had an inadequate response to one or more DMARDs (disease-modifying antirheumatic drugs such as azathioprine, gold, hydroxychloroquine, leflunomide, methotrexate, and sulfasalazine)
Crohn’s Disease (CD):
Yes No Patient has diagnosis of moderately to severely active Crohn’s Disease (adult and pediatric greater than or equal to 6 (six) years of age) manifested by one or more of following symptoms: Check boxes that apply:
Abdominal pain
Bleeding
Diarrhea
Extraintestinal manifestations (arthritis, uveitis, iritis, pyoderma gangrenosum, erythema nodosum, or spondylitis) internal fistulae
Intestinal obstruction
Perianal disease
Megacolon
Weight loss
Yes No Patient had an inadequate response to conventional therapy [oral mesalamine, oral corticosteroids, and 6-mercaptopurine or azathioprine (6-MP/AZA)]
Yes No Patient has fistulizing Crohn’s disease with draining enterocutaneous or rectovaginal fistulas, of at least 3 months duration
Yes No Patient has fistulizing or moderate to severely active Crohn’s disease who have responded to previous therapy with Remicade
Ulcerative Colitis:
Yes No Patient is 18 years of age or older
Yes No Patient has diagnosis of moderately to severely active Ulcerative Colitis
Yes No Patient has had an inadequate response to conventional therapy
Active ankylosing spondylitis (AS) (adult):
Yes No Patient is 18 years of age or older
Yes No Patient has diagnosis of active ankylosing spondylitis
Yes No Patient has failed, had an inadequate response to or is not indicated for treatment with sulfasalazine, methotrexate, or non-steroidal anti-inflammatory drugs
Active psoriatic arthritis (PsA) (adult):
Yes No Patient is 18 years of age or older
Yes No Patient is diagnosed with Psoriatic Arthritis
Yes No Patient has active arthritis with at least 5 swollen joints and 5 tender joints
Yes No Patient has presence of plaque psoriasis with a qualifying target lesion at least 2 cm in diameter
Yes No Patient has failure or contraindicated for DMARD therapy, specifically methotrexate or sulfasalazine
Patient has arthritis in any of the following distributions:
Yes No Distal interphalangeal joint involvement
Yes No Polyarticular arthritis, without rheumatoid nodules
Yes No Arthritis mutilans
Yes No Asymmetric arthritis
Yes No Ankylosing spondylitis-like arthritis
Patient’s Last Name: First Name: DOB: / /
MEDICAL CRITERIA (continued)
Chronic Plaque Psoriasis (Ps):
Yes No Disease is controlled with topical therapy
Yes No Patient has had a failure of phototherapy or other systemic therapies to achieve an adequate clinical response, or a medical contraindication to the use of phototherapy (e.g. methotrexate, acetretin, or cyclosporine)
Yes No Other systemic therapies are medically less appropriate or contraindicated
Yes No Patient has a diagnosis of moderate to severe Plaque Psoriasis
Yes No Patient has greater than 10% of body surface area with plaque psoriasis
Yes No Patient has less than or equal to 10% body surface area affected with plaque psoriasis involving sensitive areas that would significantly impact daily function (such as palms, soles of feet, head/neck, or genitalia)
Yes No Patient has diagnosis of reactive arthritis (adult) OR arthritis associated with inflammatory bowel disease
Yes No No Patient is 18 years of age or older
Juvenile Idiopathic Arthritis:
Yes No Is the patient diagnosed with moderately to severely active polyarticular juvenile idiopathic arthritis?
Yes No Has the patient been treated with one or more DMARDs and failed to achieve an adequate clinical response?
Please provide prior therapy(ies) tried: Date last Taken
/ /
/ /
/ /
Dosing Guidelines
Patient Weight: lb / kg
Rheumatoid Arthritis (RA) (adult):
3mg/kg IV in combination with methotrexate at 0, 2, and 6 weeks then every 8 weeks thereafter
For patients with an incomplete response, the dose may be increased up to 10mg/kg every 4 weeks.
Crohn’s Disease or Fistulizing Crohn’s Disease (CD):
In patients 18 years of age and older:
5mg/kg IV at 0, 2, and 6 weeks then every 8 weeks thereafter
If the individual responds and then loses response consideration may be given to increase to 10mg/kg IV or increase the frequency of administration from every 8 weeks thereafter to every 6 weeks thereafter.**
**Please note that for these conditions, the administration of Remicade® at every 6 weeks is more frequent than the FDA label indication of every 8 weeks.
In pediatric patients:
5mg/kg IV at 0, 2, and 6 weeks then every 8 weeks thereafter
Ulcerative Colitis (adult):
5mg/kg IV at week 0, 2, and 6 weeks then every 8 weeks thereafter
Active ankylosing spondylitis (AS) (adult):
5mg/kg IV at 0, 2, and 6 weeks then every 6 weeks thereafter
Active psoriatic arthritis (PsA) (adult):
5mg/kg IV at 0, 2, and 6 weeks then every 8 weeks thereafter
Methotrexate may be continued during treatment if desired
Chronic Plaque Psoriasis (Ps) (adult):
5mg/kg IV at week 0, 2, and 6 weeks then every 8 weeks thereafter
Patient’s Last Name: First Name: DOB: / /
PRESCRIPTION
Loading Dose: Remicade® (infliximab)
100mg/20ml
Directions:
Qty / 30 days: No Refills
Maintenance Dose: Remicade® (infliximab)
100mg/20ml
Directions:
Qty / 30 days: No Refills
Supplies: Yes No
Quantity
IV Start Kit (1 kit per infusion
IV Set 84” with 0.22 micron filter (1 set per infusion)
BD Insyte Autoguard Catheter (1 per infusion)
Sodium Chloride 0.9% 250cc bag (1 bag per infusion)
Sterile Water for Injection 10ml (1 vial per vial of Remicade)
BD 10cc 20G 1” syringes (1 syringe per vial of Remicade)
BD 10cc LL syringe OR
BD 30cc LL syringe OR
BD 60cc LL syringe
* Size based on number of Remicade vials per infusion multiplied by 10ml (i.e. 5 vials per infusion would require syringe large enough to draw up 50cc).
BD 22G 1” needle (1 needle per needle free syringe above)
Prescriber’s signature / Date
/ /
CuraScript is able to fill your request as written. Please provide the following information to expedite your order:
CuraScript to dispense (check box)
Ship medication to:
Physician Office Other Need by Date: : / /
*Confidentiality notice: This telecopy transmission contains confidential information belonging to the sender 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. 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 this document is strictly prohibited.
UniCare Health Plan of Kansas, Inc. ®Registered mark of WellPoint, Inc.
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
0109 KSW2402 11/11