REVIEW REQUEST FOR
Remicade® (Infliximab) -Immune Modulator
Tumor Necrosis Factor Antagonist
Provider Data Collection Tool Based on Medical Policy DRUG.00002
Policy Last Review Date: 11/03/2016 / Policy Effective Date: 11/17/2016 / Provider Tool Effective Date: 11/17/2016Request Date: //
Initial Request Subsequent Request
Buy and bill
Individual’s Name: / Date of Birth://
Insurance Identification Number: / Individual’s Phone Number:
Primary Diagnosis: / Diagnosis Code(s) (if known): / Individual’s Weight
(lbs) (kg)
Ordering Provider Name & Specialty: / Provider ID Number(if known):
Office Address:
Contact Name and Office Phone Number: / Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering Provider): / Provider ID Number(if known):
Office Address:
Contact Name and Office Phone Number: / Office Fax Number:
Place of Service: Home Office DialysisCenter OutpatientHospital
Ambulatory Infusion AmbulatoryInfusionCenter Other:
Drug Name/HCPCS Code (if known)
Remicade® J1745
Other: / Dose to be administered: (mg)
(mg/kg)
(other)
When did the individual first start this drug?
// / Frequency (Days, Wks, Months)
Duration:
(Weeks) / Start Date For This Request:
//
This, Medical Policy based, data collection tool is intended to facilitate a medical necessity review request for use of infliximab (Remicade®) in the treatment of Rheumatoid Arthritis (RA), Plaque Psoriasis (Ps), Psoriatic Arthritis (PsA), Ankylosing Spondylitis (AS), Crohn’s Disease (CD), Ulcerative Colitis (UC), Juvenile Idiopathic Arthritis (JIA), and Non-infectious Uveitis).
Part A: General Criteria Questions (must be completed)
Individual has had a tuberculin skin test (TST) or Centers for Disease Control and Prevention (CDC) recommended
equivalent to evaluate for latent tuberculosisprior to initiating infliximab (Remicade®)
Individual does not have tuberculosis, invasive fungal infection, other active serious infection, or a history of recurrent
infections
Individual will not receive Remicade®or Inflectra™ in combination with tofacitinib citrate (Xeljanz®)
Individual will not receive Remicade®or Inflectra™ in combination with other Tumor Necrosis Factor (TNF)
antagonists:(etanercept (Enbrel®), Adalimumab (Humira®), certolizumab pegol (Cimzia®), or golimumab (Simponi™))
Individual will not receive Remicade®or Inflectra™ in combination with the following non-TNF immunomodulatory
drugs: (abatacept (Orencia®), anakinra (Kineret®), or tocilizumab (Actemra®))
Select the requested drug to be used for the individual’s treatment
Request is for the use of infliximab (Remicade®)
Part B: (Only complete the section for appropriate diagnosis)
(1) Rheumatoid Arthritis (RA)
Individual isage 18 years or older and is diagnosed with moderate to severe active RA
Agent is being used to reduce signs or symptoms
Agent is being used toinduce ormaintain clinical response
Agent is being used to inhibit the progression of structural damage
Agent is being used to improve physical function
Agentwill be given in combination with methotrexate
Individual is intolerant of methotrexate and agent will be given in combination with another
immunosuppressive drug
Individual has failed to respond to, is intolerant of, or has a medical contraindication to one or more nonbiologic
disease-modifying antirheumatic drugs(DMARDs) [methotrexate, sulfasalazine (Azulfidine®),
hydroxychloroquine (Plaquenil®), Leflunomide (Arava®) or other immunosuppressants]
Please list treatmentstried:
Other:
(2) Plaque Psoriasis (Ps)
Individual isage 18 years or older andis diagnosed with chronic moderate to severe (that is,extensive or
disabling) plaque psoriasis
Plaque psoriasisinvolves greater than 5% of the body surface area (BSA)
Plaque psoriasisinvolvesless than or equal to 5% of the body surface area (BSA) presenting with
plaguepsoriasis involving sensitive areas or areas that would significantly impact daily function
(such as palms, soles of feet, head/neck, or genitalia)
Agent is being used to reduce signs or symptoms
Agent is being used to induce or maintain clinical response
Individual has failed to respond to, is intolerant of, or has a medical contraindication to phototherapy or
other systemic therapies [acitretin, cyclosporine, methotrexate]
Please list treatmentstried:
Other:
(3) Psoriatic Arthritis (PsA)
Individualage 18 years or older and is diagnosed with active psoriatic arthritis
Agent is being used to reduce signs or symptoms
Agent is being used to induce or maintain clinical response
Agent is being used to inhibit the progression of structural damage
Agent is being used to improve physical function
Individual has failed to respond to, is intolerant of, or has a medical contraindication to conventional therapy
[nonbiologic DMARDs: methotrexate, sulfasalazine (Azulfidine®),hydroxychloroquine (Plaquenil®),
corticosteroids (such as hydrocortisone, prednisone) or other immunosuppressants]
Please list treatmentstried:
Other:
(4) Ankylosing Spondylitis (AS)
Individual is age 18 years or older and has active ankylosing spondylitis
Agent is being used to reduce signs or symptoms of the disease
Individual failed to respond to, is intolerant of, or has medical contraindication to conventional therapies[such as
nonsteroidal anti-inflammatory drugs NSAIDS (such as Ibuprofen, Motrin®) or nonbiologic DMARDS
[methotrexate, sulfasalazine (Azulfidine®), hydroxychloroquine (Plaquenil®), corticosteroids (such as
hydrocortisone, prednisone) or other immunosuppressants]
Please list treatmentstried:
Other:
(5) Crohn’s Disease (CD)
Individualis age 6 years of age or older
Individual is diagnosed with fistulizing or moderate to severe active Crohn’s Disease which has responded to
previous therapy with infliximab (Remicade®)
Agent is being used to reduce the number of draining enterocutaneous or rectovaginal fistulas in an
individual with fistulizing CDof at least 3 months duration
Agent is being used to reduce sign or symptoms in an individual with moderately to severely active CD
Agent is being used to induce or maintain clinical remission in an individual with moderately to
severely active CD
Individual has failed to respond to, is intolerant of, or has a medical contraindication to conventional
therapy (such as 5-Aminosalicylic acid [5-ASA] products, sulfasalazine, systemic corticosteroids,
or immunosuppressive drugs)
Please list treatment(s) tried:
Other:
(6) Ulcerative Colitis (UC)
Individual is age 6 years or older and is diagnosed with moderately to severelyactive Ulcerative Colitis
Agent is being used to reduce signs or symptoms
Agent is being used to induce or maintain clinical remission and mucosal healing
Individual has failed to respond to, is intolerant of, or has medical contraindication to conventional
therapies [5-ASA products (e.g. Pentasa®, Rowasa®), sulfasalazine (Azulfidine®)
systemic corticosteroids (i.e. hydrocortisone, prednisone), other immunosuppressive drugs
Please list treatment(s) tried:
Other:
(7) Juvenile Idiopathic Arthritis (JIA)
Individual is 2 years of age or older and has moderately to severely active JIA
Agent is being used to reduce signs or symptoms
Agent is being used to induce or maintain clinical response
Individual has failed to respond to, is intolerant of, or has a medical contraindication to one or morenonbiologic
DMARDs: methotrexate, sulfasalazine (Azulfidine®), hydroxychloroquine (Plaquenil®), or corticosteroids (for
example,hydrocortisone, prednisone or other immunosuppressants)
Please list nonbiologic DMARDs tried:
Other:
(8) Non-infectious Uveitis
Individual has chronic, recurrent, treatment-refractory disease
Individual has vision-threatening disease
Individual has a medical contraindication to conventional therapy (such as corticosteroids or immunosuppressive
drugs [for example, azathioprine, cyclosporine, or methotrexate])
Individual has failed to respond to, is intolerant of, orhas a medical contraindication toconventional therapy
(such as corticosteroids,azathioprine, cyclosporine, methotrexate or other immunosuppressants).
Please list treatments tried:
Other:
(9) Other indications not otherwise specified above(Please submit all supporting documents including labs, progress notes,
imaging, etc., for review.)
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I confirm that the information entered on this form is accurate and complete based on the records available at the time of this request. I understand the health plan or its designees may request medical documentation to verify the accuracy of the information reported on this form.
//
Name& Title of Provider or Provider Representative Completing Form Date
& attestation (Please Print)*
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan.