State Sponsored Business, UniCare Health Plan of Kansas, Inc.

H.P Acthar® Gel (Repository Corticotropin Inj.) Enrollment Form

Page 2 of 2

Fax completed form to: CuraScript
Fax number: 1-866-545-0062 | Provider Services phone number: 1-888-662-0944
Part I Patient Information
Patient’s last name / First name / Middle initial
Address
City / State / ZIP code
Day phone number
( ) - / Night phone number
( ) - / Date of birth
/
Parent/Guardian / Allergies / Sex
M F
Primary insurance / Secondary insurance
Cardholder name (if not patient) / Cardholder name (if not patient)
Member ID and Group number / BIN# / Member ID and Group number / BIN#
Insurance phone number (+area code)
( ) - / Insurance phone number (+area code)
( ) -
Employer / Employer
Part II Physician Information (please supply copy of patient’s insurance card)
Prescriber’s name / Hospital/Clinic / Office contact name
Address
City / State / ZIP code
Phone number (+area code)
( ) - / Fax number (+area code)
( ) -
DEA number / NPI / UPIN
Part III Medical Criteria (double click on the fields below to fill in this form electronically)
Medical Criteria:
Primary Diagnosis (ICD9 Code)
Diagnostic testing of adrenocortical function
Infantile spasms (West Syndrome) (345.60-345.61)
For the following diagnosis: Indicate the corticosteroid therapy the patient has failed and the dates attempted:
Date: //
Date: //
Date: //
Constitutional red blood cell aplasia (congenital erythroblastopenia) (284.01)
Other specified aplastic anemias (acquired erythroblastopenia) (284.8)
Herpes zoster with ophthalmic complications (053.20-053.29)
Purulent and other endophthalmitis, sympathetic ophthalmia (360.00-360.19)
Rheumatic fever with heart involvement (rheumatic carditis) (391.0-391.9)
Rheumatoid arthritis & other inflammatory polyarthropathies(714.0-714.99)
Erythema multiforme (Stevens-Johnson syndrome) (695.1)
Other specified erythematous conditions(exfoliative dermatitis)(695.81-695.89)
Regional enteritis, Crohn's disease, ulcerative colitis (555.0-556.9)
Patient’s Last Name: First Name: DOB: / /
Part III Medical Criteria (continued)
Autoimmune hemolytic anemias (acquired) (283.0)
Chorioretinitis and retinochoroiditis (363.00-.363.22)
Peripheral enthesopathies and allied syndromes (762.0-726.9)
Other serum reaction (serum sickness (999.5):
Psoriatic arthropathy, other psoriasis (696.0-696.1)
Atopic dermatitis and related conditions (691.0-691.8)
Keratitis, keratoconjunctivitis (370.20-370.59)
Acute, chronic conjunctivitis (372.00-372.15)
Pulmonary eosinophilia (Loeffler's syndrome) (518.3)
Contact dermatitis and other eczema (692.0-692.9)
Dermatomyositis, polymyositis (710.3-710.4)
Synovitis and tenosynovitis (727.00-727.09)
Traumatic arthropathy (716.00-716.19)
Tuberculous meningitis (013.00-013.06)
Systemic lupus erythematosus (710.0)
Thyroiditis (245.0-245.9)
Sarcoidosis (135)
Asthma (493.0-493.9)
Proteinuria (791.0)
Hypercalcemia (275.42)
Gouty arthropathy (274.0)
Multiple sclerosis (340)
Iridocyclitis (364.00-364.3)
Trichinosis (124)
Optic neuritis (377.30-377.39)
Marginal corneal ulcer (370.01)
Mycosis fungoides (202.10-202.18)
Lymphomas (200.0-202.08)
Seborrheic dermatitis (690.10-690.18)
Specific bursitis, other bursitis (727.2-727.3)
Lymphomas, leukemias (202.20-208.91)
Bullous dermatoses (694.0-694.9)
Pulmonary tuberculosis (011.00-011.96)
Ankylosing spondylitis (720.0)
Nephrotic syndrome (581.0-581.9)
Secondary thrombocytopenia (287.4)
Allergic rhinitis due to pollen (477.0)
Dosing:
Acute Exacerbations of MS:
units IM daily for 2-3 weeks (Recommended adult dose: 80-120 units)
Other:
units IM or Sub-Q every 24-72 hours (Recommended adult dose: 40-80 units)
Days Supply: Days
Refills: 1 year 6 months Other:
Prescriber’s signature / Date
/ /
CuraScript is able to fill your request as written. Please provide the following information to expedite your order:
CuraScript to dispense (check box)
Ship medication to:
Physician Office Other Need by Date: : / /

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UniCare Health Plan of Kansas, Inc. ®Registered mark of WellPoint, Inc. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.

0109 KSW2379 11/11