01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Enbrel (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 Enbrel (Medicare Determination).
Drug Name (select from list of drugs shown)
Enbrel (etanercept)
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 Enbrel through a CVS Caremark administered benefit for one of the following conditions?
    Y   N    
   Rheumatoid arthritis \ Juvenile idiopathic arthritis \ Ankylosing spondylitis \ Psoriatic arthritis \ Plaque psoriasis
   [If no, skip to question 6.]
  5. Has the patient’s condition improved or stabilized with Enbrel?
    Y   N    
   [If yes, skip to question 24.]
   [If no, no further questions.]
  6. Prior to initiating disease-modifying anti-rheumatic drug (DMARD) therapy, did the patient have a diagnosis of moderately to severely active RA?
    Y   N    
   [If no, skip to question 10.]
  7. Has the patient tried and had an inadequate response to methotrexate (MTX)?
    Y   N    
   [If yes, skip to question 19.]
  8. Has the patient tried and had an inadequate response to another nonbiologic DMARD (e.g., leflunomide, hydroxychloroquine, sulfasalazine, injectable gold)?
    Y   N    
   [If yes, skip to question 19.]
  9. Does the patient meet ONE of the following?
    Y   N    
   Intolerance or contraindication to at least 2 nonbiologic DMARDs \ Enbrel will be used as first-line therapy with MTX for severely active RA
   [If yes, skip to question 19.]
   [If no, no further questions.]
  10. Prior to initiating therapy, did the patient have a diagnosis of polyarticular juvenile idiopathic arthritis?
    Y   N    
   [If no, skip to question 12.]
  11. Has the patient had an inadequate response to at least one nonbiologic DMARD or intolerance/contraindication to at least 2 nonbiologic DMARDs?
    Y   N    
   [If yes, skip to question 19.]
   [If no, no further questions.]
  12. Prior to initiating therapy, did the patient have a diagnosis of psoriatic arthritis with predominantly peripheral symptoms?
    Y   N    
   [If no, skip to question 14.]
  13. Has the patient had an inadequate response to at least an 8-week maximum tolerated dose trial of at least 1 nonbiologic DMARD unless contraindicated or intolerant to such therapy?
    Y   N    
   [If no, no further questions.]
   [If yes, skip to question 19.]
  14. Prior to initiating therapy, did the patient have a diagnosis of psoriatic arthritis with predominantly axial symptoms or active ankylosing spondylitis?
    Y   N    
   [If no, skip to question 16.]
  15. Has the patient had an inadequate response or intolerance/contraindication to at least 2 nonsteroidal anti-inflammatory drugs (NSAIDs)?
    Y   N    
   If yes, skip to question 19.]
   [If no, no further questions.]
  16. Prior to initiating therapy, did the patient have a diagnosis of chronic moderate to severe plaque psoriasis?
    Y   N    
   Affects a body surface area greater than 10% OR \ Affects crucial body areas (hands, feet, face, neck and/or groin)
   [If no, no further questions.]
  17. Has the patient had an insufficient response to at least a 60-day trial of 2 conventional therapies (e.g., phototherapy, calcipotriene, MTX, acitretin) or has an intolerance/contraindication to such therapies?
    Y   N    
   [If no, no further questions.]
  18. Is the patient 18 years of age or older?
    Y   N    
   [If no, no further questions.]
  19. 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, no further questions.]
  20. Was the patient positive for latent TB infection?
    Y   N    
   [If no, skip to question 23.]
  21. Has active TB been ruled out?
    Y   N    
   [If no, no further questions.]
  22. Is the patient currently receiving or has the patient completed treatment for latent TB infection?
    Y   N    
   [If no, no further questions.]
  23. Prior to initiating therapy, has the patient been evaluated for hepatitis B virus (HBV) risk, and if appropriate, HBV infection been ruled out or treatment initiated?
    Y   N    
   [If no, no further questions.]
  24. Will Enbrel be used in combination with another biologic agent?
    Y   N    
   [If yes, no further questions.]
  25. 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