State Sponsored Business, UniCare Health Plan of Kansas, Inc.

Psoriasis and Psoriatic Arthritis Enrollment Form

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Fax completed form to: CuraScript
Fax 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)
PRIMARY DIAGNOSIS
Psoriasis (ICD-9 696.1) Psoriatic arthropathy (ICD-9 696.0)
PASI______
Patient weight: lb / kg Date taken / /
Are any of the following present? (Check all that apply)
History of recurrent, current chronic or clinically important infection or positive tuberculin skin test
Currently receiving phototherapy, systemic psoriasis therapy (except for methotrexate, glucocorticoids, salicylates, NSAIDs, or analgesics, immunosuppressive therapy, or anakinra)
Pregnant or nursing
CD4+ T lymphocyte count <250 cells per millimeter
History of systemic malignancy within the last 5 years

Patient’s Last Name: First Name: DOB: / /

Part III Medical Criteria (continued)
Plaque Psoriasis Criteria (Check all that apply)
Greater than 10% of body surface area with plaque psoriasis OR less than or equal to 10% body surface area with plaque psoriasis involving sensitive areas or areas that would significantly impact daily function (such as palms, soles of feet, head/neck, or genitalia)
Candidate for systemic and/or phototherapy
Failed prior systemic therapy and/or phototherapy OR systemic/phototherapy is contraindicated. If contraindicated, specify reason:
Psoriatic Arthritis Criteria (Check all that apply)
Patient has at least 3 swollen joints and at least 3 tender joints
Presence of plaque psoriasis with a qualifying target lesion at least 2cm in diameter
Failed previous trial of methotrexate or sulfasalazine OR contraindication to methotrexate or sulfasalazine. If contraindication, specify reason:
PRESCRIPTIONS
Remicade (Infliximab) 100mg single dose vials
Dose mg / kg Total dose:
Induction: infuse at 0, 2, and 6 weeks
Maintenance: infuse every 8 weeks (check both boxes if new therapy)
Remicade infusion supplies
Amevive® (alefacept) 15mg vials for intramuscular injection
Raptiva® (efalizumab) 125mg single use vials (4/pk)
Humira® (adalimumab)
Humira PED pen (20mg/0.4mL) Humira pen KIT (40mg/0.8ml; 2 pen kit)
Humira pen STARTER kit Humira Pre-Filled Syringe (2/pk)
Enbrel® (etanercept)
25mg/0.5 mL PFS (4/Pk) 25mg/mL MDV (4doses/Pk)
50mg Sureclick (replacement) 50mg/mL PFS (4/pk) 50mg/mL PFS (Replacement)
Directions:
Quantity: 4 weeks Other: Refills:
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 KSW240 1 11/11