Adalimumab (Humira®) J0135
Please fax completed CMN forms and other required documentation (i.e., physician history and physical; physician progress notes; with documentation of conservative treatment including prior medications used; treatment plan including narrative): / Statewide Fax Number: 1-904-905-9849Section A
Physician Information
Name:
/BCBSF Number:
/National Provider Identifier (NPI):
Street Address:
City:
/County:
/State:
/ZIP:
Telephone Number:
/Fax Number:
Contact Name:
Facility Information
Name:
/BCBSF Number:
/National Provider Identifier (NPI):
Street Address:
City:
/County:
/State:
/ZIP:
Telephone Number:
/Fax Number:
Contact Name:
Member Information
Last Name: / First Name:Member/Contract Number (alpha and numeric): / Date of Birth:
Section B
Procedure Code (HCPCS): / Medication Name:
ICD-9 Code: / Diagnosis Description:
This medication is: administered by the Provider. self-administered by the patient.
Yes No N/A Is patient picking up medication at a retail pharmacy?
Yes No N/A Is provider buying the medication and billing BCBSF directly?
Yes No N/A Is provider obtaining medication from Caremark for drug replacement?
This is: an initial request. continuation of therapy. restart.
If continuation, what date was therapy initiated? / Current Daily Dosage:
If restart, what dates was therapy previously used? / Why was therapy stopped and restarted?
Prescribed Dosage: / Dosing Frequency: / Dosing administration route:
Section C
Check the box and complete the questions applicable to the patient’s condition:
Rheumatoid ArthritisYes No / Patient has a history of beneficial clinical response to adalimumab therapy for rheumatoid arthritis and dosage does not exceed 40 mg every other week if methotrexate is used concomitantly or dosage does not exceed 40 mg weekly if methotrexate is not being used
Yes No / Patient is 18 years of age or older
Yes No / Patient has had an inadequate response to one or more DMARDs (disease modifying antirheumatic drugs). Adalimumab may be used alone OR in combination with methoxate or other DMARDs
Yes No / If methotrexate is used concomitantly, dosage does not exceed 40 mg every other week OR if methrotrexate is not used concomitantly, dosage does not exceed 40 mg weekly.
Juvenile Idiopathic Arthritis
Yes No / Patient has a history of beneficial clinical response to adalimumab therapy for juvenile idiopathic arthritis and dosage does not exceed 20 mg every other week if patient weighs less than 30 kg or does not exceed 40 mg every other week if patient weighs more than 30 kg
Yes No / Adalimimab is prescribed for reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis (JIA)
Yes No / Patient is 4 years of age or older
Yes No / Patient has had an inadequate response to one or more DMARDs
Yes No / For patients weighing between 15 kg (33 lbs) to <30 kg (66 lbs, dosage does not exceed 20 mg every other week OR for patients weighing >30 kg (66 lbs), dosage does not exceed 40 mg every other week.
Psoriatic Arthritis
Yes No / Patient has a history of beneficial clinical response to adalimumab therapy for psoriatic arthritis and dosage does not exceed 40 mg every other week
Yes No / Patient is 18 years old or older
Yes No / Adalimab is prescribed to reduce the signs and symptoms of psoriatic arthritis as single therapy or in combination with a DMARD
Yes No / Dosage does not exceed 40 mg every other week.
Ankylosing Spondylitis
Yes No / Patient has a history of beneficial clinical response to adalimumab therapy for ankylosing spondylitis and dosage does not exceed 40 mg every other week
Yes No / Patient is 18 years old or older
Yes No / Adalimab is prescribed to reduce the signs and symptoms of psoriatic arthritis as single therapy or in combination with a DMARD
Yes No / Dosage does not exceed 40 mg every other week.
Crohn’s Disease
Yes No / Patient has a history of beneficial clinical response to adalimumab therapy for Crohn’s disease and dosage does not exceed 40 mg every other week
Yes No / Patient 18 years of age or older
Yes No / Adalimumab is prescribed for reducing signs and symptoms of moderately to severely active Crohn’s disease and inducing and maintaining clinical remission in adult patients
Yes No / Patient has had an inadequate response to conventional therapy or have lost response to or are intolerant to infliximab
Yes No / Initial dosing does not exceed 160 mg at week 0, and 80 mg at week 2AND maintenance dose does not exceed 40 mg every other week.
Plaque Psoriasis
Yes No / Patient has a history of beneficial clinical response to adalimumab therapy for plaque psoriasis and dosage does not exceed 40 mg every other week
Yes No / Patient 18 years of age or older
Yes No / Adalimumab is prescribed for adult patients with moderate to severe chronic plaque psoriasis
Yes No / Patient must have failed to adequately respond to or is intolerant to one of the following phototherapies(unless contraindicated):
Yes No / psoralens (methoxsalen, trioxsalen) with UVA light (PUVA); OR
Yes No / UVB with coal tar or dithranol; OR
Yes No / UVB (standard or narrow-band) AND
Yes No / Initial dose does not exceed 80 mg at week 0 AND maintenance dose does not exceed 40 mg every other week starting at week 1.
Check any and all DMARDsthe patient has attempted that failed:
Auranofin (oral gold) (Ridaura)
Azathioprine (Imuran)
Cyclophosphamide (Cytoxan)
Cyclosporine (Neoral, Sandimmune)
Gold sodium thiomalate (injectable gold) (Myochrysine)
Hydroxychloroquine sulfate (Plaquenil)
Leflunomide (Arava)
Methotrexate (Rheumatrex, Trexall)
Minocycline (Minocin)
Penicillamine (Cuprimine, Depen)
Sulfasalazine (Azulfidine, Azulfidine EN-Tabs)
Other:
Comments:
My signature below certifies that the information submitted on this form is accurate and these services are medically necessary.
Ordering Physician’s Signature: / Date:Certificate of Medical Necessity: Adalimumab (Humira®)1