Kansas Medical Assistance Program P O Box 3571 Topeka, KS 66601-3571 Provider 1-800-933-6593 Beneficiary 1-800-766-9012

Prior Authorization for Non-Preferred Immunomodulation Agents (Formerly Biologics) *Clinical prior authorization may apply for all agents

Immunomodulation Agents For Adult Rheumatoid Arthritis Preferred Non-Preferred, Prior Authorization Required Enbrel® (etanercept) Actemra® (tocilizumab) Humira® (adalimumab) Cimzia® (certolizumab) Xeljanz® (tofacitinib) Kineret® (anakinra) Xeljanz XR® (tofacitinib) Orencia® (abatacept) Remicade® (infliximab) Rituxan® (rituximab) Simponi Aria® (golimumab) Simponi® (golimumab)

Immunomodulation Agents For Ankylosing Spondylitis Preferred Non-Preferred, Prior Authorization Required Enbrel® (etanercept) Cosentyx® (secukinumab) Humira® (adalimumab) Remicade® (infliximab) Simponi® (golimumab)

Immunomodulation Agents For Crohn’s Disease Preferred Non-Preferred, Prior Authorization Required Humira® (adalimumab) Cimzia® (certolizumab) Entyvio® (vedolizumab) Remicade® (infliximab) Stelara® (ustekinumab) Tysabri® (natalizumab)

Immunomodulation Agents For Juvenile Idiopathic Arthritis Preferred Non-Preferred, Prior Authorization Required Enbrel® (etanercept) Actemra® (tocilizumab) Humira® (adalimumab) Orencia® (abatacept)

Immunomodulation Agents For Plaque Psoriasis Preferred Non-Preferred, Prior Authorization Required Enbrel® (etanercept) Amevive® (alefacept) Humira® (adalimumab) Cosentyx® (secukinumab) Otezla® (apremilast) Remicade® (infliximab) Stelara® (ustekinumab) Taltz® (ixekizumab)

Prior Authorization Phone # Page 1 of 2 1-800-285-4978 Revised April 2017 Kansas Medical Assistance Program P O Box 3571 Topeka, KS 66601-3571 Provider 1-800-933-6593 Beneficiary 1-800-766-9012

Prior Authorization for Non-Preferred Immunonodulation Agents

Immunomodulation Agents For Psoriatic Arthritis Preferred Non-Preferred, Prior Authorization Required Enbrel® (etanercept) Cosentyx® (secukinumab) Humira® (adalimumab) Remicade® (infliximab) Otezla® (apremilast) Simponi® (golimumab) Stelara® (ustekinumab)

Immunomodulation Agents For Ulcerative Colitis Preferred Non-Preferred, Prior Authorization Required Humira® (adalimumab) Entyvio® (vedolizumab) Remicade® (infliximab) Simponi® (golimumab)

Beneficiary Information Name: Medicaid ID #: Date of Birth: Pharmacy Information Name: Medicaid ID #: NPI #: Phone #: Fax #: Requested Drug: NDC: Prescriber Information Name: Medicaid ID # NPI #: Phone #: Fax #: Non-Preferred Prior Authorization Please check the appropriate box and provide the required information to receive the requested non-preferred drug.  If there is one preferred agent in the preferred category, has patient tried and failed the one preferred agent in the last 180 days (unless medical intolerance/allergy)?  Yes  No  Intolerance/allergy  If there are two or more agents in the preferred category, has patient tried and failed two preferred agents in the last 180 days (unless medical intolerance/allergy to all agents in the preferred class)?  Yes  No  Intolerance/allergy to all preferred agents  An appropriate formulation or indication is not available as a preferred drug. Please specify which formulation or indication is needed and information supporting the need: Prescriber’s Signature: Date: The completed form should be faxed to the HPE Prior Authorization Unit at 1-800-913-2229. This form will be returned unprocessed if it is not completed in its entirety.

Prior Authorization Phone # Page 2 of 2 1-800-285-4978 Revised April 2017