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					                                                                                                SPECIAL AUTHORIZATION REQUEST

                                                                                                               RHEUMATOID ARTHRITIS
                                                       Fax requests to (902) 368-4905 OR mail requests to PEI Drug Programs, P.O. Box 2000, Charlottetown, PE, C1A 7N8
PEI DRUG PROGRAMS                                                                   HIGH-COST DRUG PATIENT APPLICATION ALSO REQUIRED PRIOR TO COVERAGE.


SECTION 1 – PATIENT INFORMATION
PERSONAL HEALTH NUMBER (PHN)                                                 PATIENT (FAMILY) NAME                           PATIENT (GIVEN) NAME(S)


DATE OF BIRTH (YYYY/MM/DD)                         PATIENT WEIGHT (kg) PATIENT'S MAILING ADDRESS
                     |             |

SECTION 2 – PRESCRIBER INFORMATION
NAME AND MAILING ADDRESS                                                                                            APPLICATION DATE
                                                                                                                             YYYY                      MM             DD
                                                                                                                                             |                 |
                                                                                                                    PRESCRIBER'S TELEPHONE #
                                                                                                                      AREA CODE
                                                                                                                                       |
                                                                                                                    PRESCRIBER'S FAX #
                                                                                                                      AREA CODE
                                                                                                                                       |

SECTION 3 – MEDICATION DETAIL INFORMATION
REQUESTED DRUG (PLEASE CHECK ONE)
 Adalimumab (Humira) – Maximum adult coverage is for 40mg every two weeks.
 Etanercept (Enbrel) - Maximum adult coverage is for 50mg weekly or 25mg twice weekly. Pediatric patients 4-17 years of age, coverage is 0.8mg/kg weekly to a maximum
of 50mg weekly.
 Infliximab (Remicade) - Maximum adult coverage is for 3mg/kg/dose at 0, 2 and 6 weeks, then every 6-8 weeks
 Alternate Biologic (Abatacept [Orencia]; Fill Out Section 4)

SECTION A: INITIAL 6 MONTH COVERAGE CRITERIA (USE SECTION B FOR CONTINUED COVERAGE)
- Approval for anti-TNF agents will NOT be considered in combination with other biologic agents.


CHECK RELEVANT BOXES BELOW:
- An adequate trial is considered to be 5 months for IM Gold, 6 Months for Penicillamine, 4 months for Hydroxychloroquine and 3 months for all other traditional DMARDs.
- Unless limited by toxicity, Methotrexate dosage should be increased up to 25mg/week unless a response is achieved at a lower dose.


1)  Medication is being prescribed by a rheumatologist;
2)  Patient has not responded to a trial consisting of at least 3 months of Leflunomide;
3a)  Patient has not responded or has had intolerable toxicity to an adequate trial of Methotrexate and at least one of the following DMARDs:
      IM Gold  Sulfasalazine       Hydroxychloroquine      Azathioprine  Chloroquine  Penicillamine
OR
3b)  Patient is intolerant to or has a contraindication to Methotrexate and is refractory to a combination of at least two of the following DMARDs:
      IM Gold  Sulfasalazine       Hydroxychloroquine      Azathioprine  Chloroquine  Penicillamine
OR
3c)  Patient is not a candidate for combination DMARD therapy but has had an adequate trial of Methotrexate and at least two of the following DMARDs in sequence:
      IM Gold  Sulfasalazine       Hydroxychloroquine      Azathioprine  Chloroquine  Penicillamine


SECTION B: CONTINUED COVERAGE
- Coverage is for a maximum of 12 months. Renewal will require reassessment of the patient and submission of a new Rheumatoid Arthritis Special Authorization Request
Form.
CHECK/FILL OUT RELEVANT BOXES BELOW:
- Efficacy:  Minimal     Moderate  Marked


CURRENT THERAPY (PLEASE CHECK ONE)                                                     DOSAGE AND FREQUENCY                                  PATIENT WEIGHT (kg)
 Adalimumab (Humira)  Etanercept (Enbrel)  Infliximab (Remicade)



                                      FORMS WITH INFORMATION MISSING WILL BE RETURNED FOR COMPLETION.                                                       09/2010
                            APPROVALS WILL NOT BE CONSIDERED AT DOSES OR DOSING INTERVALS OUTSIDE OF PEI GUIDELINES.
CONCURRENT RHEUMATOID ARTHRITIS THERAPY

         DRUG                                              DOSE                                                      FREQUENCY




SECTION 4 – ALTERNATE BIOLOGIC (ABATACEPT) MEDICATION DETAIL INFORMATION
REQUESTED COVERAGE
 Initial Coverage - Initial coverage will be approved for five doses administered at 0,2,4,8 and 12 weeks. Coverage is for a dose of 500mg if <60kg, 750mg if 60-100kg and
1000mg if >100kg. Pediatric patients 6-17 years of age and <75kg, coverage is for 10mg/kg based on weight at administration.
 Continued Coverage (Complete Section B) - Continued coverage (beyond five doses) will be approved for intervals of every 4 weeks.
- Approval will NOT be considered in combination with anti-TNF agents.


SECTION A: INITIAL 16 WEEK COVERAGE CRITERIA
PLEASE CHECK/FILL OUT THE RELEVANT BOXES BELOW:
 Medication is being prescribed by a rheumatologist;

 Patient has failed to respond to an adequate trial of an anti-TNF agent:

 ANTI-TNF AGENT                              DOSE                                       FREQUENCY                                   LENGTH OF TX




AND


 Patient is currently receiving one DMARD (unless agent is contraindicated), listed below:

DMARD                                                      DOSE                                                      FREQUENCY




DMARD CONTRAINDICATION (REASON/DESCRIBE)




SECTION B: CONTINUED COVERAGE FOR ALTERNATE BIOLOGIC (ABATACEPT)
- Coverage is for a maximum of 12 months. Renewal will require reassessment of the patient and submission of a new Rheumatoid Arthritis Special Authorization Request
Form.
- Patient must show a 20% improvement in symptoms (document below):
- ACR20 ________ Date of Assessment_______________.


The PEI Drug Programs may request additional documentation to support this Special Authorization Request. Personal information on this form is collected under section
31(c) of Prince Edward Island's Freedom of Information & Protection of Privacy (FOIPP) Act as it relates directly to and is necessary for providing services under the PEI High-
Cost Drugs Program.


If you have any questions about this collection of personal information, you may contact the program office at 902-368-4947 or at the address at the top of the form.



________________________________________________________________________________________________
PRESCRIBER SIGNATURE (REQUIRED)                                                                                                  DATE




                                     FORMS WITH INFORMATION MISSING WILL BE RETURNED FOR COMPLETION.                                                      09/2010
                           APPROVALS WILL NOT BE CONSIDERED AT DOSES OR DOSING INTERVALS OUTSIDE OF PEI GUIDELINES.

				
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