Remicade (Infliximab) -Immune Modulator

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: 11/17/2016

Request 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.