01/03/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Actemra (Medicare Determination)

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 1-866-239-8303.
Please contact CVS/Caremark at 1-800-294-5979 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of Actemra (Medicare Determination).
Drug Name (select from list of drugs shown)
Actemra (tocilizumab)
Patient Information
Patient Name:    
Patient ID:    
Patient Group No.:    
Patient DOB:    
Prescribing Physician
Physician Name:    
Physician Phone:    
Physician Fax:    
Physician Address:    
City, State, Zip:    
Diagnosis:     ICD Code:  
Please circle the appropriate answer for each question.
  1. Is the physician purchasing and providing the drug “incident to” physician services (i.e., drugs supplied and administered by a physician or under a physician’s direct supervision)?
    Y   N    
   [If the answer to this question is yes, then no further questions required.]
  2. Is the patient in a long-term care (LTC) bed that is covered by Medicare?
    Y   N    
  3. Is the request for one of the following drugs via an IV infusion pump?
    Y   N    
   Acyclovir \ Foscarnet \ Amphotericin B \ Fluorouracil \ Cytarabine \ Bleomycin \ Doxorubicin \ Vincristine \ Vinblastine \ Treprostinil (Remodulin) \ Cisplatin \ Gemcitabine \ Oxaliplatin \ Morphine
  4. Has the patient previously received Actemra through a CVS Caremark administered benefit for either of the following:
    Y   N    
   Rheumatoid arthritis (RA) \ Systemic juvenile idiopathic arthritis
   [If no, skip to question 6.]
  5. Has the patient responded to Actemra therapy (e.g., condition improved or stabilized)?
    Y   N    
   [If yes, skip to question 15.]
   [If no, no further questions.]
  6. Prior to initiating therapy, did the patient have a diagnosis of moderately to severely active adult RA?
    Y   N    
   [If no, then skip to question 8.]
  7. Did the patient have a contraindication, inadequate response to or was intolerant of a TNF inhibitor?
    Y   N    
   [If yes, then skip to question 10.]
   [If no, no further questions.]
  8. Prior to initiation of Actemra, did the pediatric patient have a diagnosis of systemic juvenile idiopathic arthritis (sJIA) with active systemic features (e.g., fevers)?
    Y   N    
   [If no, no further questions.]
  9. Did the patient have a contraindication, intolerance, or inadequate response to corticosteroids?
    Y   N    
   [If no, then no further questions.]
  10. Prior to initiating therapy, has the patient been screened for latent TB infection with either a TB skin test or an interferon gamma release assay (e.g., QFT-GIT, T-SPOT.TB)?
    Y   N    
   [If no, then no further questions.]
  11. Was the patient positive for latent TB infection?
    Y   N    
   [If no, skip to question 14.]
  12. Has active TB been ruled out?
    Y   N    
   [If no, no further questions.]
  13. Is the patient currently receiving or has the patient completed treatment for latent TB infection?
    Y   N    
   [If no, no further questions.]
  14. Prior to initiating therapy, has the patient been evaluated for hepatitis B virus (HBV) risk, and if appropriate, HBV infection ruled out or treatment initiated?
    Y   N    
   [If no, no further questions.]
  15. Will Actemra be used in combination with another biologic agent?
    Y   N    
   [If yes, no further questions.]
  16. Does the patient have an active infection (chronic or localized)?
    Y   N    

Comments:  

I affirm that the information given on this form is true and accurate as of this date.

 
Prescriber (Or Authorized) Signature and Date