Prolia Prior Authorization Form/ Prescription - Ambetter

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Prolia
Prior Authorization Form/ Prescription
Date: ___________ Date Medication Required:____________
Phone: (855) 304-5580 Fax: (855) 521-1728
Ship to:
Physician
Patient’s Home
Other __________
Patient Information
Last Name:
First Name:
Middle:
DOB: ____/____/_____
Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Sex:
Male
Female
Insurance Information (Attach Copies of cards)
Primary Insurance:
Secondary Insurance:
ID #
Group #
ID #
Group #
City:
State:
City:
State:
Physician Information
Name:
Specialty:
NPI:
Address:
City:
State:
Zip:
Phone # (
)
Secure Fax #: (
)
Office contact:
Prescription Information
MEDICATION
STRENGTH
DIRECTIONS
QUANTITY
REFILLS
Prolia
Primary Diagnosis
Primary ICD-9/ICD-10 Code: ___________________________
Osteoporosis
Cancer treatment-induced bone loss
Other___________________________
Clinical Information
***** Please submit supporting clinical documentation*****
INITIAL THERAPY
CONTINUATION OF THERAPY
; Therapy start date: _____________________________
1. Does the patient have normal serum calcium level?
Yes
No
2. Is the patient currently on or will be receiving supplemental calcium plus vitamin D?
Yes
No
3. Baseline T-score? _____________
Current T-score ___________________ (please fax copy of results)
For osteoporosis diagnosis
4. Prolia is prescribed for:
Postmenopausal osteoporosis
To increase bone mass in a man with osteoporosis
5. Is the patient at least 50 years of age with a fragility fracture?
Yes
No
6. Has the patient failed a trial of one year course of oral bisphosphonate therapy AND Reclast?
Yes
No
7. If yes, was the patient adherent to prescribed therapy?
Yes
No
8. If no, is the patient contraindicated or intolerant to oral bisphosphonate therapy AND Reclast?
Yes
No
For cancer treatment-induced cancer
9. What is the cancer indication?
Prostate cancer
Breast cancer
Other ____________________
10. Does the patient have metastatic disease?
Yes
No
11. Is the patient receiving androgen deprivation therapy?
Yes
No
12. Is the patient receiving adjuvant aromatase inhibitor therapy?
Yes
No
Physician’s Signature
Date: ________________________
DAW
________________________________________________

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