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UNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete this form in its entirety and send to Rocky Mountain Health Plans at 8583572538 Urgent 1 Monument
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How to Fill Out Actemra IV:

01
Gather all necessary supplies, including Actemra IV vial, IV infusion set, sterile alcohol wipes, and gloves.
02
Ensure proper hand hygiene by washing hands thoroughly with soap and water or using hand sanitizer.
03
Carefully inspect the Actemra IV vial for any signs of damage or contamination. Do not use if the vial is cracked or the liquid appears discolored.
04
Clean the rubber stopper of the vial with a sterile alcohol wipe to maintain aseptic conditions.
05
Using a syringe, withdraw the prescribed dose of Actemra IV from the vial. Follow the instructions provided by your healthcare provider or pharmacist to determine the accurate dosage.
06
If additional medications are required, ensure compatibility by consulting with a healthcare professional or referring to the medication reference guide.
07
Attach the IV infusion set to the Actemra IV vial following the manufacturer's instructions. Ensure a secure connection.
08
Prime the IV infusion set to remove any air bubbles by allowing the Actemra IV solution to flow through the tubing until a steady stream is observed.
09
Apply gloves to ensure aseptic technique during the administration process.
10
Locate a suitable injection site for Actemra IV. Common sites include the inner forearm, the back of the hand, or the upper arm. Clean the chosen site with a sterile alcohol wipe.
11
Insert the needle attached to the IV infusion set into the previously cleaned injection site at the proper angle. Secure the needle in place.
12
Begin the Actemra IV infusion by adjusting the flow rate to the prescribed speed. This may be controlled by a mechanical pump or manually regulated by a healthcare professional.
13
Monitor the infusion site, vital signs, and any potential adverse reactions throughout the administration process.
14
Once the Actemra IV infusion is completed, dispose of all used materials in accordance with appropriate medical waste disposal guidelines.

Who Needs Actemra IV:

01
Actemra IV is a medication typically prescribed for the treatment of rheumatoid arthritis (RA) in adults.
02
It may also be used to manage other inflammatory conditions like giant cell arteritis, systemic juvenile idiopathic arthritis, and cytokine release syndrome (CRS) in patients receiving CAR-T cell therapy.
03
Actemra IV is usually recommended when the disease is severe or when oral medications are not sufficient.
04
The decision to prescribe Actemra IV is made by a healthcare professional, taking into account the individual's medical history, disease severity, response to other treatments, and potential risks and benefits.
05
It is important to follow your healthcare provider's instructions and regularly communicate any changes in symptoms or concerns for proper ongoing treatment optimization.
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