Xolair Specialty Medication - Statement Of Medical Necessity Form
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1XOLAIR ® (OMALIZUMAB) SPECIALTY MEDICATION
STATEMENT OF MEDICAL NECESSITY
Tel: (800) 906-7798
Please complete this form (PRINT) in its entirety and fax it to the number below.
Fax: (877) 381-3806
Be sure to enclose any necessary documentation, labs, insurance cards, etc.
PATIENT DEMOGRAPHICS
PRESCRIBER INFORMATION
SEX: M F
PATIENT NAME: ______________________________________________
PRESCRIBER’S NAME: _____________________________________________________
ALLERGIES:________________________________ Weight: ______lbs/kg Height:______
MD LICENSE #: ______________________ MD NPI#: ___________________________
DATE OF BIRTH: _______________ SOCIAL SECURITY #: ________________________
CLINIC NAME: _______________________________SPECIALTY:___________________
A
CONTACT NAME: ________________________________________________________
DDRESS: _________________________________________________ APT#_________
ADDRESS: _________________________________ SUITE #: ____________________
CITY: ______________________________________ STATE: ______ ZIP: __________
CITY: _________________________________ STATE: ________ ZIP: ____________
HOME PHONE: ________________________ WORK PHONE: ______________________
PHONE: _____________________________ FAX: ______________________________
CELL PHONE: ________________________ EMAIL: ______________________________
INSURANCE INFORMATION
Please include copies of the patient’s insurance/drug benefit cards (front and back) .
PRIMARY INSURANCE: _______________________________________ RELATIONSHIP:
SELF
SPOUSE
CHILD
POLICY #: __________________________________
OTHER INSURANCE: _________________________________________ POLICY #: _____________________________ INSURANCE PHONE #: _______________________________
CLINICAL INFORMATION
FOR APPROPRIATE PATIENTS WITH ALLERGIC ASTHMA
ICD-9/ICD-10:
493.90/J45.909 Asthma, unspecified type, unspecified
493.00/J45.20 Extrinsic asthma/unspecified
493.20/J44.9 Chronic obstructive asthma, unspecified
Other ICD-9/ICD-10: ___________________________
(Complete to the highest level of specificity)
Pretreatment serum IgE level IU/mL (1.0 kU/L=1.0 IU/mL; 2.4 ng/mL=1.0 IU/mL):
IgE level: _____________________ Test date: _______________________ Patient weight: _______________ kg
Weight date: _______________
History of positive skin or RAST test to a perennial aeroallergen
FOR APPROPRIATE PATIENTS WITH CIU
Moderate to severe allergic persistent asthma
ICD-9/ICD-10:
708.1/L50.1 Idiopathic urticaria
ER visits/hospitalizations
Date(s): ______________
708.8/L50.8 Other specified urticaria
Unscheduled office visits
Date(s): ______________
708.9/L50.9 Urticaria, unspecified
FEV 1 (if available): ____________ %
Other ICD-9/ICD-10:
Other asthma therapies
(Complete to the highest level of specificity)
Short-acting beta-agonist (SABA).......................
Current
Past
Patient has had CIU for 6 weeks or more
Current
Past
Inhaled corticosteroids (ICS without LABA).........
Other CIU therapies
Current
Past
Long-acting beta-agonist (LABA without ICS)......
H1 antihistamines
Current
Past
Combination therapy (ICS/LABA)........................
Other:
Current
Past
Oral and/or injectable steroids............................
Other (specify):
Current
Past
PLEASE SUBMIT CLINICAL NOTES TO SUPPORT DIAGNOSIS
PRESCRIPTION INFORMATION
1) PRESCRIPTION TYPE:
NEW START
RESTART
CONTINUING TREATMENT
2) SIG (Check With an “X” & Complete Accordingly):
□
□
□
OR
OR
SUBCUTANEOUSLY EVERY 4 WEEKS:
SUBCUTANEOUSLY EVERY 2 WEEKS:
OTHER DOSE:
□
□
150MG/DOSE
225MG/DOSE
___________MG/DOSE
□
□
300MG/DOSE
300MG/DOSE
EVERY___________WEEKS
□
375MG/DOSE
3) REFILL_________TIMES
DISPENSE_________ DILUENT: 10-CC VIAL PRESERVATIVE-FREE STERILE WATER USP FOR INJECTION; ANCILLARY SUPPLIES: 3-CC SYRINGES AS NEEDED FOR
RECONSTITUTION; 18-GAUGE NEEDLES AS NEEDED FOR RECONSTITUTION; 25-GAUGE NEEDLES AS NEEDED FOR ADMINISTRATION
______________________________________
_____________________________________
Prescriber’s Signature
Date:
Substitution Allowed
Deliver Medication to:
Patient’s Home
Physician’s Office
Other: _______________________________
On behalf of Keystone Health Plan® Central, ACRO Pharmaceutical Services LLC assists in the administration of physician-
administered specialty medications. ACRO Pharmaceutical Services in an independent company. Capital BlueCross is an Independent
licensee of the BlueCross BlueShield Association.
Thank you for Choosing Acro Pharmaceutical Services!
FAX COMPLETED FORM TO: (877) 381-3806
Important Notice: This communication contains information that is confidential and protected from disclosure. If the reader of this message is not the intended recipient, employee or agent responsible for delivering
the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please reply
to the sender that you have received the message in error and destroy this copy.
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