Prescriber Fax Form

SOLIRIS PRIOR AUTHORIZATION REQUEST PRESCRIBER FAX FORM Only the prescriber may complete this form. This form is for prospective, concurrent, and retrospective reviews. The following documentation is REQUIRED. Incomplete forms will be returned for additional information. For formulary information please visit www.myprime.com. Start saving time today by filling out this prior authorization form electronically. Visit covermymeds.com to begin using this free service. What is the priority level of this request? Standard review Expedited/Urgent review – prescriber certifies that waiting for a standard review could seriously harm the patient’s life, health or ability to regain maximum function Today’s Date: ____________________ PATIENT AND INSURANCE INFORMATION Date of Service (if differs from Today’s Date): ___________________ Patient Name (First): Last: M: DOB (mm/dd/yyyy): Patient Address: City, State, Zip: Patient Telephone: Member ID Number: Group Number: PRESCRIBER/CLINIC INFORMATION Prescriber Name: Prescriber NPI#: Specialty: Contact Name: Clinic Name: Clinic Address: City, State, Zip: Phone #: Secure Fax #: PLEASE ATTACH ANY ADDITIONAL INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST Patient’s Diagnosis: Paroxysmal Nocturnal Hemoglobinuria (PNH) Atypical Hemolytic Uremic Syndrome (aHUS) Generalized Myasthenia Gravis (gMG) Neuromyelitis Optica Spectrum Disorder (NMOSD) Other (ICD code plus description): ______________________________________________________________________ Medication Requested: Strength: Dosing Schedule: Quantity per Month: For all requests: 1. What is the patient’s weight? ___________________ (kg) 2. Is the patient currently being treated with the requested agent? ............................................................................ Yes No 3. Has the patient received a meningococcal vaccine at least two weeks prior to receiving the first dose of Soliris? Please note, medical records are required............................................................................................ Yes No If no, do the risks of delaying Soliris therapy outweigh the risk of developing a meningococcal infection? Please note, medical records are required. ................................................................................................... Yes No For paroxysmal nocturnal hemoglobinuria (PNH): 4. Will the requested agent be used to reduce hemolysis? ........................................................................................ Yes No 5. Was the patient's diagnosis confirmed through analysis by one of the following: 1) flow cytometry of erythrocytes for CD59 deficiency, or 2) granulocytes for either CD59 or CD55? Please note, medical records are required. ............. Yes No For generalized myasthenia gravis (gMG): 6. Has the patient had a positive serologic test for anti-acetylcholine receptor?........................................................ Yes No 7. Is the patient Myasthenia Gravis Foundation of America (MGFA) Clinical Classification Class II to IV? .............. Yes No 8. Does the patient have a Myasthenia Gravis Activities of Daily Living (MG-ADL) total score ≥ 6? ......................... Yes No 9. Did the patient fail treatment over 1 year or more with a minimum of 2 immunosuppressive therapies either in combination or as monotherapy? ............................................................................................................................ Yes No If no, did the patient fail at least 1 immunosuppressive therapy and required chronic plasmapheresis or plasma exchange or intravenous immunoglobulin (IVIG)? ................................................................................ Yes No Please continue to the next page. 6124 BOEING SOLI PRIME THERAPEUTICS LLC 04/21 Page 1 of 2 Patient Name (First): Last: M: DOB (mm/dd/yyyy): For neuromyelitis optica spectrum disorder (NMOSD): 10. Is the patient anti-aquaporin-4 (AQP4) antibody positive? ..................................................................................... Yes No 11. Will the patient receive eculizumab concurrently with other biologics used to treat NMOSD (e.g., inebilizumab-cdon, rituximab, satralizumab)? ........................................................................................................................................ Yes No Please fax or mail this form to: CONFIDENTIALITY NOTICE: This communication is Prime Therapeutics LLC intended only for the use of the individual entity to which it is Clinical Review Department addressed, and may contain information that is privileged or 2900 Ames Crossing Road Eagan, MN 55121 confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, TOLL FREE distribution or copying of this communication is strictly Phone: Fax: 877.243.6930 prohibited. If you have received this communication in error, Aetna/Cigna + Prime: 800.421.6022 please return the original message to Prime Therapeutics via U.S. Mail. Thank you for your cooperation. BCBSIL/Prime: 888.802.8776 6124 BOEING SOLI PRIME THERAPEUTICS LLC 04/21 Page 2 of 2 .

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