Get the free USTEKINUMAB (Stelara®) injection PRIOR REVIEW/CERTIFICATION FAXBACK FORM
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This document serves as a prior review and certification request form for the prescription of Ustekinumab (Stelara®) injection, ensuring all necessary patient and prescriber information is provided
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How to fill out ustekinumab stelara injection prior
How to fill out USTEKINUMAB (Stelara®) injection PRIOR REVIEW/CERTIFICATION FAXBACK FORM
01
Start by collecting patient information including name, date of birth, and insurance details.
02
Fill out the prescribing physician's information including name, contact number, and NPI number.
03
Indicate the patient's diagnosis relevant to USTEKINUMAB treatment.
04
Complete the medication information section by specifying USTEKINUMAB (Stelara®) dosage and frequency.
05
Provide previous treatments and outcomes relevant to the patient's condition.
06
Attach any necessary clinical documentation such as lab results or previous treatment records.
07
Sign and date the form to certify the accuracy of the provided information.
08
Submit the completed faxback form as per the guidelines provided by the insurance company.
Who needs USTEKINUMAB (Stelara®) injection PRIOR REVIEW/CERTIFICATION FAXBACK FORM?
01
Patients diagnosed with conditions such as psoriasis, psoriatic arthritis, or Crohn's disease.
02
Healthcare providers prescribing USTEKINUMAB for these patients to obtain prior authorization from insurance providers.
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People Also Ask about
What conditions is STELARA approved for?
STELARA is currently approved for the treatment of adults living with moderately to severely active CD and ulcerative colitis, in addition to the treatment of adults and children six years and older with active psoriatic arthritis and moderate to severe plaque psoriasis.
How do you start STELARA?
STELARA® treatment starts with a one-time IV infusion through a vein in your arm that provides the amount of medication based on your body weight and is administered by a medical professional in a comfortable setting. It takes at least 1 hour to receive the full dose of medicine.
How immunocompromised does STELARA make you?
You're more likely than usual to get a cold when you're using Stelara. This drug slows down the activity of your immune system, reducing your body's ability to fight off infections. With lowered immunity, you have a higher risk of catching a cold. The common cold is an infection caused by viruses.
What is the FDA approved indication for STELARA?
STELARA® is indicated for the treatment of adults and pediatric patients 6 years of age and older with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.
Is STELARA a registered trademark?
STELARA is a registered trademark of Johnson & Johnson. See US Prescribing Information for further information. Key Eligibility Criteria: Adult patients with moderately to severely active Crohn's disease.
What is STELARA in English?
Ustekinumab, sold under the brand name Stelara among others, is a monoclonal antibody medication used for the treatment of Crohn's disease, ulcerative colitis, plaque psoriasis and psoriatic arthritis, targeting both IL-12 and IL-23. It is administered either by intravenous infusion or subcutaneous injection.
What tests are needed before starting STELARA?
Before beginning ustekinumab treatment, you will need blood tests to check for hepatitis B and tuberculosis infections. You may also need to test for tuberculosis every year. Blood counts and liver tests are done every 4 months while on ustekinumab.
What labs are needed prior to starting STELARA?
You will need to have a negative tuberculosis (TB) test before beginning Ustekinumab therapy. Your doctor will also check your blood to make sure you do not have Hepatitis B or C.
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What is USTEKINUMAB (Stelara®) injection PRIOR REVIEW/CERTIFICATION FAXBACK FORM?
The USTEKINUMAB (Stelara®) injection PRIOR REVIEW/CERTIFICATION FAXBACK FORM is a document used to obtain approval from insurance providers or health plans before administering the USTEKINUMAB injection for conditions such as psoriasis, Crohn's disease, or ulcerative colitis.
Who is required to file USTEKINUMAB (Stelara®) injection PRIOR REVIEW/CERTIFICATION FAXBACK FORM?
Healthcare providers, including physicians or clinics administering the USTEKINUMAB injection, are typically required to file the PRIOR REVIEW/CERTIFICATION FAXBACK FORM.
How to fill out USTEKINUMAB (Stelara®) injection PRIOR REVIEW/CERTIFICATION FAXBACK FORM?
To fill out the form, providers must provide patient demographic information, details about the patient's medical condition, the proposed treatment, relevant medical history, and any previous treatments tried.
What is the purpose of USTEKINUMAB (Stelara®) injection PRIOR REVIEW/CERTIFICATION FAXBACK FORM?
The purpose of the form is to ensure that the proposed use of USTEKINUMAB is medically necessary and to facilitate insurance reimbursement by obtaining prior authorization.
What information must be reported on USTEKINUMAB (Stelara®) injection PRIOR REVIEW/CERTIFICATION FAXBACK FORM?
The form must report the patient's name, date of birth, insurance information, the diagnosis, details of the requested treatment, including dosage and frequency, and any prior treatments or medications related to the condition.
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