Remicade Order Form - Florida Health Care Plans

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