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This document is used for submitting a request for predetermination related to the drug Remicade, specifically for various conditions such as Crohn's Disease, Rheumatoid Arthritis, and others, requiring

How to fill out remicade predetermination request

How to fill out Remicade Predetermination Request

1. Obtain the Remicade Predetermination Request form from your healthcare provider or insurance company.
2. Fill in the patient's personal information, including name, address, and date of birth.
3. Provide detailed medical history relevant to the condition being treated with Remicade.
4. Include specific diagnosis codes, such as ICD-10 codes, that correspond to the condition.
5. Document previous treatments tried and their outcomes, if applicable.
6. Attach any necessary lab results or imaging studies that support the need for Remicade.
7. Clearly specify the dosage and frequency of Remicade treatment proposed.
8. Sign and date the form as required.
9. Submit the completed form to your insurance provider for review.

Who needs Remicade Predetermination Request?

1. Patients diagnosed with conditions such as Crohn's disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, or psoriasis who require treatment with Remicade.
2. Individuals who have tried other treatments without success and their healthcare provider deems Remicade necessary.

People Also Ask about

Does REMICADE require premedication?

Prior to infusion with REMICADE®, patients may be premedicated with histamine-1 receptor antagonists, histamine-2 receptor antagonists, acetaminophen, and/or corticosteroids. For mild to moderate reactions during the infusion, consider slowing or stopping the infusion.

Who prescribes REMICADE?

Only your doctor can recommend a course of treatment after checking your health condition. REMICADE® () can cause serious side effects such as lowering your ability to fight infections.

Does REMICADE need premeds?

Approximately 20% of REMICADE-treated patients in all clinical trials experienced an infusion reaction compared with 10% of placebo-treated patients [see Adverse Reactions (6.1)]. Prior to infusion with REMICADE, premedication may be administered at the physician's discretion.

What to do before a REMICADE infusion?

Before you Arrive Drink Up! It's a good idea to show up to your. infusion well hydrated. Pack Up! is administered over a period of. about 2 hours. Bring a book, laptop, tablet, or. Dress Up! It's important to dress for the occasion. Make comfort a priority and wear. loose-fitting clothing and layers in case.

What are the indications for REMICADE?

Crohn's Disease. REMICADE® is indicated for: Pediatric Crohn's Disease. Ulcerative Colitis. Pediatric Ulcerative Colitis. Rheumatoid Arthritis. Ankylosing Spondylitis. Psoriatic Arthritis. Plaque Psoriasis.

What is the protocol for REMICADE?

The recommended dosage of REMICADE® is 5 mg/kg given as an intravenous induction regimen at 0, 2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter for the treatment of active PsA. REMICADE® can be used with or without methotrexate.

Does REMICADE require prior authorization?

All requests for Remicade () and Biosimilars require a prior authorization and will be screened for medical necessity and appropriateness using the criteria listed below. Biosimilars include Renflexis™, Inflectra™, and Ixifi™.

What premedication is given before ?

Premedications were commonly used prior to every infusion (Figures 1 and 2). Regardless of practice type, the majority of respondents reported using an antihistamine (69.7%) or acetaminophen (66.2%) routinely and diphenhydramine was the second most commonly used premedication (63.6%).

For pdfFiller’s FAQs

What is Remicade Predetermination Request?

A Remicade Predetermination Request is a formal request submitted to an insurance provider to determine whether a specific treatment involving the medication Remicade will be covered under the patient's insurance policy.

Who is required to file Remicade Predetermination Request?

The healthcare provider prescribing Remicade, typically a physician or specialist, is generally responsible for filing the Remicade Predetermination Request on behalf of the patient.

How to fill out Remicade Predetermination Request?

To fill out a Remicade Predetermination Request, the healthcare provider should complete the appropriate forms provided by the insurance carrier, including patient information, diagnosis, treatment plan, and medical necessity supporting documentation.

What is the purpose of Remicade Predetermination Request?

The purpose of the Remicade Predetermination Request is to obtain prior authorization from the insurance provider, ensuring that the proposed treatment is covered and to avoid unexpected costs for the patient.

What information must be reported on Remicade Predetermination Request?

The information that must be reported includes patient demographics, diagnosis codes, treatment indications, previously tried medications, medical history, and any supporting clinical documentation to justify the need for Remicade.