Provider Bulletin: Subject s1

Anthem Blue Cross and Blue Shield State Sponsored Business Enbrel® (etanercept) and Humira® (adalimumab) Enrollment Form Fax completed form to: PrecisionRx Specialty Solutions Fax number: 1-866-862-3170 | Provider Services phone number: 1-888-662-0944 Part I Patient Information Patient’s last name First name Middle initial

Address City County 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 County State ZIP code

Phone number (+area Fax number (+area DEA number NPI number UPIN code) code) ( ) - ( ) - Part III Medical Criteria (double click on the fields below to fill in this form electronically) Medical Criteria: Primary Diagnosis (ICD9 Code) ______Secondary Diagnosis (ICD9 Code) ______Patient Weight: lb / kg Prior Therapy: Has patient received previous treatment Yes No If yes, drug(s) used and dates of therapy: Drug: ______Date: / / Duration: ______Drug: ______Date: / / Duration: ______Approval Criteria for Enbrel® and Humira®: Ankylosing spondylitis (AS) (adult) : Yes No Patient is 18 years of age or older Yes No Patient has diagnosis of Ankylosing Spondylitis Yes No Patient has failed, had an inadequate response to or is not indicated for treatment with sulfasalazine, methotrexate, or non-steroidal anti-inflammatory drugs Chronic Moderate to Severe Plaque Psoriasis (Ps): Yes No Patient is 18 years of age or older Yes No Patient has a diagnosis of moderate to severe Plaque Psoriasis AND Yes No Patient has greater than 10% of body surface area with plaque psoriasis OR Yes No Patient has less than or equal to 10% body surface are affected with plaque psoriasis involving sensitive areas that would significantly impact daily function (such as palms, soles of feet, head/neck, or genitalia Yes No Patient has failed or has a contraindication to systemic therapies? If yes, what systemic therapy has the patient tried? methotrexate acitretin cyclosporine phototherapy

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. PrecisionRx Specialty Solutions is a pharmacy and department of NextRx, LLC. 0609 INW2386 06/05/09 State Sponsored Business, Anthem Blue Cross and Blue Shield Enbrel® (etanercept) and Humira® (adalimumab) Enrollment Form Page 2 of 5

Patient First Name: ______Patient Last Name: ______DOB: / / Part III Medical Criteria (continued) Crohn’s Disease (CD) *** FOR Humira ONLY***: Yes No Patient has been diagnosed with moderately to severely active Crohn’s Disease Yes No Patient had an inadequate response to conventional therapy [oral mesalamine, oral corticosteroids, and 6- mercaptopurine or azathioprine (6-MP/AZA)] Yes No Patient has not been previously treated with a tumor necrosis antagonist Yes No Patient has been previously treated with infliximab (Remicade) but have lost response to or are intolerant to infliximab (Remicade) Juvenile Idiopathic Arthritis (JIA): Yes No Is the patient diagnosed with moderately to severely active polyarticular juvenile idiopathic arthritis? Yes No Has the patient been treated with one or more DMARDs and failed to achieve an adequate clinical response? Please provide prior therapy(ies) tried: Date last Taken: / / / / / / Psoriatic arthritis (PsA) (adult): Yes No Patient is 18 years of age or older Yes No Patient is diagnosed with Psoriatic Arthritis Yes No Patient has active arthritis with at least 3 swollen joints and 3 tender joints Yes No Patient has presence of plaque psoriasis with a qualifying target lesion at least 2 cm in diameter Yes No Patient has failure or contraindicated for DMARD therapy, specifically methotrexate or sulfasalazine Patient has arthritis in any of the following distributions: Yes No Distal interphalangeal joint involvement Yes No Polyarticular arthritis, without rheumatoid nodules Yes No Arthritis mutilans Yes No Asymmetric arthritis Yes No Ankylosing spondylitis-like arthritis Rheumatoid Arthritis (RA): Yes No Patient has a diagnosis of moderately to severely active Rheumatoid Arthritis Yes No Patient is 18 years of age or older Yes No Patient has failed or had an inadequate response to one or more DMARDs. If yes, what DMARD has the patient tried? Azulfidine (sulfasalazine) Methotrexate Cytoxan (cyclosphosphamide) Cuprimine/Depen (penicillamine) Plaquenil (hydroxychloroquine) Cyclosporine (Neoral or Sandimmune) Imuran (azathioprine) Ridaura (auanofin) Minocycline (Minocin or Dynacin) Leflunomide (Arava) Gold Sodium Thiomalate (Myochrysine) State Sponsored Business, Anthem Blue Cross and Blue Shield Enbrel® (etanercept) and Humira® (adalimumab) Enrollment Form Page 3 of 5

Enbrel® (etanercept): Ankylosing spondylitis (AS) (adult): 50mg Sub-Q weekly, given as one 50mg injection on one day Chronic Plaque Psoriasis (Ps) (adult): 50mg Sub-Q twice weekly given 3 or 4 days apart for 3 months followed by a reduction to the maintenance dose of 50mg Sub-Q weekly Juvenile Idiopathic Arthritis (JIA) (ages 2 to 17 years old): (25mg pre-filled syringe is not recommended for the pediatric patients weighing less than 31kg (68lbs)) 0.8mg/kg/wk up to a maximum of 50mg Sub-Q/week given as one or two injections in one day or separated by 72 to 96 hours patients weighing 63kg (138lbs or more) can use the 50mg pre-filled syringe or SureClick™ autoinjector as a single dose Psoriatic arthritis (PsA) (adult): 50mg Sub-Q weekly given as one 50mg injection on one day Rheumatoid Arthritis (RA) (adult): 50mg Sub-Q weekly given as one 50mg injection on one day State Sponsored Business, Anthem Blue Cross and Blue Shield Enbrel® (etanercept) and Humira® (adalimumab) Enrollment Form Page 4 of 5

Patient First Name: ______Patient Last Name: ______DOB: / / Part III Medical Criteria (continued) Enbrel® Prescription: 25mg/0.5mL Prefilled Syringe 25mg/1mL Vial 50mg/1mL Prefilled Syringe 50mg/1mL Sureclick Autoinjector Loading Dose: Inject 25mg Sub-Q TWICE weekly for 3 months Inject 50mg Sub-Q TWICE weekly for 3 months Other: Maintenance Dose: Inject 25mg Sub-Q TWICE weekly (72-96 hours apart) Inject 50mg Sub-Q ONCE weekly Other: Quantity: 28-day supply 84-day supply Other: Refills: 1 Year 6 months Other: Humira® (adalimumab): Ankylosing spondylitis (AS) (adult): 40mg (0.8ml) Sub-Q every other week Chronic Plaque Psoriasis (Ps) (adult): 80mg initial dose Sub-Q, followed by 40mg (0.8ml) Sub-Q every other week starting one week after initial dose Crohn’s Disease (CD): an induction dose of 160mg Sub-Q with an 80mg dose Sub-Q at week two, followed by maintenance dose of 40mg Sub-Q every other week beginning at week four the initial dose may be given as four injections on one day, or divided over two days Juvenile Idiopathic Arthritis (ages 4 to 17 years old): patients weighing 15kg (33lbs) to < 30kg (66lbs), 20mg Sub-Q every other week (can use 20mg pre-filled syringe) patients weighing ≥ 30kg (66lbs), 40mg Sub-Q every other week (can use pen or 40mg pre-filled syringe Psoriatic arthritis (PsA) (adult): 40mg (0.8ml) Sub-Q every other week Rheumatoid Arthritis (RA) (adult): 40mg (0.8m) Sub-Q every other week in some patients not on methotrexate additional benefit may be derived from increasing the dosing frequency to 40mg Sub-Q once weekly Humira® Prescription: 20mg/0.4mL PED Prefilled Syringe (2 syringes/pack) 40 mg (10.8 mL) Pen Starter Kit (6 syringes/pack) 40mg/0.8mL Pen Kit (2 Syringes/pack) 40mg/0.8mL Prefilled Syringe (2 Syringes/pack) Loading Dose: Psoriasis Inject two 40mg pens (80 mg total) Sub-Q for first dose (Day 1), then one 40mg Sub-Q inj. one week after first dose (Day 8), then one 40mg Sub-Q inj. three weeks after first dose (day 22) Inject two 40mg pens (80 mg total) Sub-Q, then 40mg Sub-Q every other week one week after initial inj. Other: Crohn’s Disease 160mg Sub-Q at week 0, 80mg Sub-Q at week 2 (Day 15) 80mg Sub-Q day 1, then 80mg Sub-Q day 2, then 80mg Sub-Q day 15 Other: Maintenance Dose: Inject 20mg Sub-Q every other week Inject 40mg Sub-Q every other week Inject 40mg Sub-Q every week Other: Quantity: 30-day supply 90-day supply Refills: 1 Year 6 months Other: ______Prescriber’s signature Date / / State Sponsored Business, Anthem Blue Cross and Blue Shield Enbrel® (etanercept) and Humira® (adalimumab) Enrollment Form Page 5 of 5

PrecisionRx Specialty Solutions is able to fill your request as written. Please provide the following information to expedite your order: PrecisionRx Specialty Solutions to dispense (check box) Ship medication to: Patient Home Physician Office Other *Confidentiality notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited.