Remicade Order Form - Florida Health Care Plans

FLORIDA HEALTH CARE PLANS
REMICADE ORDER
Date: Auth. #:
A. Member Name: Referring Provider Name:
Med. Record #: Date of Birth: Referring Provider Phone #:
Home Phone#: Work Phone# Referring Provider FHCP #:
Cell #:
Subscriber #:
Parent/Guardian Name:
Provider Signature:
Copy to:
Allergies:
Type of Referral: URGENT ROUTINE
Administer PPD Weight DIAGNOSIS CODE
REMICADE Dose
Frequency
Pre-medicate with:
NONE
Benadryl 25mg PO Benadryl 50mg PO Repeat as needed.
Tylenol 650mg PO Repeat as needed
Prednisone 40mg PO Prednisone 40mg IV Other
If B/P decreases between 15 & 20 mmHg, or patient experiences symptoms indicating Hypersensitivity
(urticaria, dyspnea, hypotension, heart rate decrease, dizziness, chest pain) stop infusion and give
Benadryl 25mg PO Benadryl 50mg PO Repeat as needed
Tylenol 650mg PO Prednisone 40mg Po Prednisone 40mg IV
Other
* Refer to Centocor Algorithm for Remicade
____________________________
Physician Signature
REASON FOR REFERRAL: (Attach all supporting documentation)
THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION
This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be
authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s
PCP or the Referring Provider.
APPROVED BY FLORIDA HEALTH CARE PLANS FOR:
Signature:
Date:
TO: FROM: Phone #:
This document is privileged and confidential. It is intended solely for the use of the recipient named above. If the reader/recipient of this document is not the intended recipient,
you are hereby notified that any distribution, copying or disclosure of the contents of this document is prohibited. If you have received this document in error, please notify
FHCP immediately by the telephone or fax number indicated above and return the original facsimile message to us at P. O. Box 9910, Daytona Beach, FL 32120.
21-110/10-07RX

PROCEDURE FOR ORDERING REMICADE
Remicade is a monoclonal antibody agent known to be effective in the treatment of Crohn’s Disease and Rheumatoid
Arthritis, Ulcerative Colitis, Ankylosing Spondylitis, and Psoriatic Arthritis.
Approval for treatment of Crohn’s Disease is based on failure of both an anti-inflammatory agent (5-ASA compounds,
sulfasalazine, Dipentum, Pentasa, Asacol & Rowasa) and an immunosuppressant (purinethol, azothioprine,
methotrexate). Intermittent steroids and antibiotics used to manage exacerbations and maintain remission are not
sufficient to satisfy immunosuppressant and anti-inflammatory trials.
Approval for treatment of Ulcerative Colitis is based on history of moderate to severe ulcerative colitis in patients who
have contraindications to or have failed both therapeutically effective doses of Aminosalicilates (sulfasalizine 4-
6g/day, mesalamine 2-4.8g/day, balsalazide 6.75g/day, olsalazine 1.5-3g/day), and an Immunomodulator (6-
mercaptopurine or azothioprine) or continuous corticosteroid. Approved injections will be covered at weeks 0,2,6, and
then every 8 weeks at the labeled dosage (5mg/kg).
Approval for treatment of rheumatoid arthritis (RA), And Psoriatic Arthritis is based on failure of Humira (2 nd in line
to Enbrel failures). Note: Remicade is only indicated for treatment of RA in combination with methotrexate.
PROCEDURE:
• Ordering physician will send completed Remicade order (form 21-110) and supporting documentation to the
FHCP Referral Department
• Order must include dose of REMICADE, frequency, Pre-medication order and orders to follow if reaction to
infusion
• Documentation of PPD within one year or order for PPD before first treatment.
• If approved, Referral Department will notify physician office and send signed form to FHCP Infusion Clinic:
‣ Daytona Facility
‣ Orange City Facility
‣ Palm Coast Facility
‣ Edgewater Facility
• Infusion Clinic will call patient to set up appointment for PPD
• Infusion Clinic Nurse will place and read PPD, and assess for any s / s infection
• If patient has a previous positive PPD, order chest x-ray with copy to Infusion Clinic
• Infusion nurse will assess for signs and symptoms of TB and document on nurse assessment and Remicade
order form
• Infusion Clinic Nurse will send order for Remicade to Pharmacy
• Clinic will schedule patient for appointment for Remicade infusion
• Medicare patients will pick up medication at Pharmacy and bring with him/her to appointment at Infusion
Clinic, all other members Remicade will be shipped to infusion clinic.
• Ordering physician will provide patient with information and educational materials
21-110/10-07RX