Enzyme replacement precert form

Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Page 1 of 2 (Please complete & return only page 1 if Aetna Specialty Pharmacy is NOT the dispensing provider.) No Does DNA Analysis confirm evidence of genetic If this Precert is request for Elaprase: No Is the patient diagnosed with Hunter syndrome MPS II? If this Precert request is for Aldurazyme: If this Precert request is for Fabrazyme: Which form of MPSI is the patient diagnosed with: No Is the patient diagnosed with Fabry disease? If this Precert request is for Lumizyme: No Is the patient diagnosed with late-onset (non-infantile) Scheie form of MPSI with moderate to severe symptoms No Is the patient age 8 years or older? If this Precert request is for Cerezyme, Ceredase or VPRIV: No Does the patient have evidence of cardiac hypertrophy? No Does the patient have Type 1 Gaucher disease? No Does the patient have infantile-onset Pompe disease? If this Precert request is for Naglazyme: Moderate to severe anemia (Hgb ≤ 11.5g/dl for females or 12.5g/dl No Is the patient diagnosed with mucopolysaccharidosis VI? Significant hepatomegaly (liver size 1.25 or more times normal – No Does the patient have mild to moderate Type 1 Gaucher Significant splenomegaly (Spleen size 5 or more times normal – If yes, please check all that apply for enzyme replacement therapy not Skeletal disease beyond mild osteopenia and Erlenmeyer flask Symptomatic disease, including abdominal or bone pain, fatigue exertional limitation, weakness or cachexia Thrombocytopenia (platelet count ≤ to 120,000/mm3) Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Page 2 of 2 (Please complete & return only page 1 if Aetna Specialty Pharmacy is NOT the dispensing provider.) F. PRESCRIPTION INFORMATION – To be completed only if Aetna Specialty Pharmacy is Dispensing Provider (circle selection) - Available in 2.9mg/5ml single dose vials - Further dilute with Sodium Chloride 0.9% Sodium Chloride 0.9% 100ml (for patients weighing 20kg or less) - Further dilute with 0.1% Albumin (Human) Sodium Chloride 0.9% 250ml (for patients weighing greater than 20kg) - Available in 200U and 400U single dose - Sterile Water for Injection for reconstitution - Further dilute with Sodium Chloride 0.9% - Available in 5mg and 35mg single dose vials - Sterile Water for Injection for reconstitution - Further dilute with Sodium Chloride 0.9% - Sterile Water for Injection for reconstitution - Further dilute with Sodium Chloride 0.9% hours every two weeks. Further dilute with: - Sterile Water for injection for reconstitution - Further dilute with Sodium Chloride 0.9% - Available in 5mg/5ml single dose vials Sodium Chloride 0.9% 100ml (for patients weighing ≤ 20kg or susceptible to fluid overload - Further dilute with Sodium Chloride 0.9% Sodium Chloride 0.9% 250ml (for patients weighing greater than 20kg) NS Flush: - Available in 200U and 400U single dose - Sterile Water for Injection for reconstitution Further dilute with Sodium Chloride 0.9% to final volume of - Further dilute with Sodium Chloride 0.9% - Available in 6mg (2mg/ml 3ml) single dose vials - Further dilute with 100ml of 0.9% Sodium Chloride To order contact Zavesca.com (phone 888-281-5582 / fax 866-413-4139) *If Aetna Specialty Pharmacy is the dispensing pharmacy, patient benefits will be verified before product is shipped. *If the prescriber is providing the drug, the provider must verify benefits. (Required by law if this Precertification Request is also used as an Aetna Specialty Pharmacy prescription order.) Interchange is mandated unless practitioner writes the words “NO SUBSTITUTION” in this space:

Source: http://www.aetnahealthcare.net/provider/data/Enzyme_Replacement_Precert_Form.pdf