- - Xolair ® (omalizumab) Injectable Medication Precertification Request Page 1 of 2 Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-752-7021 FAX: 1-888-267-3277 For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263 (All fields must be completed and legible for precertification review) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / / Precertification Requested By: Phone: Fax: A. PATIENT INFORMATION First Name: Last Name: DOB: Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: E-mail: Patient Current Weight: lbs or kgs Patient Height: inches or cms Allergies: B. INSURANCE INFORMATION Aetna Member ID #: Group #: Insured: Does patient have other coverage? Yes No If yes, provide ID#: Carrier Name: Insured: Medicare: Yes No If yes, provide ID #: Medicaid: Yes No If yes, provide ID #: C. PRESCRIBER INFORMATION First Name: Last Name: (Check one): M.D. D.O. N.P. P.A. Address: City: State: ZIP: Phone: Fax: St Lic #: NPI #: DEA #: UPIN: Provider E-mail: Office Contact Name: Phone: Specialty (Check one): Allergist Pulmonologist ENT Pediatrician Primary Care Other: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION Place of Administration: Self-administered Physician’s Office Outpatient Infusion Center Phone: Center Name: Home Infusion Center Phone: Agency Name: Administration code(s) (CPT): Address: Dispensing Provider/Pharmacy: (Patient selected choice) Physician’s Office Retail Pharmacy Specialty Pharmacy Other: Name: Address: Phone: Fax: TIN: PIN: E. PRODUCT INFORMATION Request is for Xolair (omalizumab): Dose: Frequency: F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other where applicable. Primary ICD Code: Secondary ICD Code: Other ICD Code: G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests. For Initiation Requests (clinical documentation required for all requests): Asthma Does the patient have positive skin test or in vitro reactivity to at least 1 perennial aeroallergen? Yes No Please indicate the patient’s pre-treatment IgE level (IU/mL): ACTION REQUIRED: Please attach chart notes or medical record showing pre-treatment IgE level. Does the patient have inadequate asthma control (e.g., hospitalization or emergency medical care visit within the past year) despite current treatment with inhaled corticosteroid and additional controller (long acting beta2-agonist, leukotriene modifier, or sustained- release theophylline) at optimized doses? Yes No Will the patient receive Xolair as monotherapy (i.e., without any other asthma medications such as inhaled corticosteroids)? Yes No Will the patient receive Xolair concomitantly with other biologics (e.g., Cinqair, Dupixent, Fasenra, Nucala)? Yes No Chronic idiopathic urticaria (CIU) Please indicate how long the patient had a spontaneous onset wheals and/or angioedema (in weeks): Does the patient remain symptomatic despite treatment with a second-generation H1 antihistamine (e.g., cetirizine, fexofenadine, levocetirizine, loratadine) for at least 2 weeks? Yes ACTION REQUIRED: If ‘Yes’, please attach supporting chart note(s) documenting an inadequate symptomatic relief after at least 2 weeks of treatment with a second-generation H1 antihistamine. No Has the patient been evaluated for other causes of urticaria, including bradykinin-related angioedema and interleukin-1-associated urticarial syndromes (auto-inflammatory disorders, urticarial vasculitis)? Yes No For continuation requests: (Clinical documentation required for all requests) Is this continuation request a result of the patient receiving samples or a manufacturer’s patient assistance program? (Sampling of Xolair does not guarantee coverage under the provisions of the pharmacy benefit) Yes No Asthma Has the patient’s asthma control improved on Xolair therapy as demonstrated by a reduction in the frequency or severity of symptoms and exacerbations? Yes No Continued on next page GR-68457 (1-20)