Remicade (infliximab) - Immune Modulators

REVIEW REQUEST FOR
Remicade ® (infliximab) - Immune Modulators
Provider Data Collection Tool Based on Medical Policy DRUG.00002
AIM Specialty Pharmacy Review
(888) 223-0550
Policy Last Review Date: 11/13/2014 Policy Effective Date: 11/17/2014 Provider Tool Effective Date: 11/17/ 2014
Request Date: / /
Initial Request
Buy and bill
Individual’s Name:
Insurance Identification Number:
Subsequent Request
Date of Birth:
/ /
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:
Servicing Provider Name & Specialty (If different than Ordering Provider):
Office Fax Number:
Provider ID Number(if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Place of Service: Home Office Dialysis Center Outpatient Hospital
Ambulatory Infusion Ambulatory Infusion Center Other:
Drug Name/HCPCS Code (if known)
Dose to be administered:
Remicade ® J1745
Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
/ /
Duration:
Start Date For This Request:
(Weeks)
/ /
(mg)
(mg/kg)
(other)
Part A: General Criteria Questions (must be completed)
Individual has had a tuberculin skin test (TST) or Centers for Disease Control (CDC) recommended equivalent to evaluate
for latent tuberculosis prior 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 in combination with tofacitinib citrate (Xeljanz ® )
Individual will not receive in combination with other Tumor Necrosis Factor (TNF) antagonists: (etanercept (Enbrel®),
Adalimumab (Humira®), certolizumab pegol (Cimzia®), or golimumab (Simponi))
Individual will not receive in combination with the following non-TNF immunomodulatory drugs: (abatacept (Orencia®),
anakinra (Kineret®), or tocilizumab (Actemra®))

Part B: (Only complete the section for appropriate diagnosis)
(1) Rheumatoid Arthritis (RA)
Individual is age 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 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
Infliximab will be given in combination with methotrexate
Individual is intolerant of methotrexate and will be given in combination with another
immunosuppressive agent
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 treatments tried:
Other:
(2) Plaque Psoriasis (Ps)
Individual is age 18 years or older and is diagnosed with chronic moderate to severe (that is, extensive or
disabling) plaque psoriasis
Plaque psoriasis involves greater than 5% of the body surface area (BSA) Plaque psoriasis involves
less than or equal to 5% of the body surface area (BSA) presenting with plague psoriasis 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 treatments tried:
Other:
(3) Psoriatic Arthritis (PsA)
Individual age 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 treatments tried:
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 treatments tried:
Other:

(5) Crohn’s Disease (CD)
Individual is age 6 years of age or older
Individiual 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 CD of 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 conventioinal
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 severely active 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 more nonbiologic
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, or has a medical contraindication to conventional 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 attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the 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.