Fillable Xolair Request Form - Blue Cross & Blue Shield printable pdf download

XOLAIR

(Omalizumab)

Request Form

Please fax completed form to DSP Care Management Fax: 601-664-5004 / Phone: 1-866-940-4281

For Mississippi State and School Employees’ Health Insurance Plan members, contact Catalyst Rx at 1-866-757-7839.

For Federal employees, contact Medco at 1-800-262-7890 for mail-order or Caremark at 1-877-727-3784 for retail pharmacy.

Patient Information

Blue Cross & Blue Shield of Mississippi does not provide pharmacy management to these members.

Name

Home Phone

Alternate Phone

Address

City

State

Zip Code

Male

Female

Date of Birth

Alternate Contact

Relationship

Home Phone

Alternate Phone

Insurance Information

Primary Insurance

Secondary Insurance

Identification Number

Subscriber Name

Relationship to Patient

Prescriber Information

Prescriber Name

Phone

Fax

Office Contact Name

Mailing Address

City

State

Zip Code

Physical Address

City

State

Zip Code

DEA Number

License Number

NPI

Diagnosis and Clinical Information

Primary ICD-9

Secondary ICD-9

Other Asthma

Short-acting Beta-agonist

Inhaled Corticosteroids

Combination Therapy

Therapies:

Long-acting Beta-agonist

Leukotriene Modifier

Oral Steroids

Other

(specify)______________________

Lab Results

History of positive skin or RAST test to a perennial aeroallergen

Patient Weight __________ kg

(Check all that apply)

(Divide lbs by 2.2 to obtain kg)

Pretreatment serum lgE level __________ IU/mL

Test Date ________________

Date __________________________

(1.0 kU/L = 1.0 IU/mL; 2.4 ng/mL = 1.0 IU/mL)

Medical Justification for Initiation or Continuation of Xolair

Diagnosed with asthma for __________ mos/yrs

(additional information may be attached if necessary)

Compliant with asthma medications

Samples given to patient __________________________________

(list medications/dates)

__________________________________

Prescription

Prescription Type:

New Start

Continued Tx

Drug Allergies:

NKDA

After six months of therapy, documentation of patient’s improvement must be submitted for continuation of treatment.

Please dispense Xolair

(Omalizumab) for subcutaneous use.

Dispense:

Refill __________ time(s)

Physician Buy and Bill

Subcutaneously, every 4 weeks:

Outpatient Hospital

150-mg dose

Use DSP Pharmacy

300-mg dose

Accredo

Vital Care of Meridian

OR Subcutaneously, every 2 weeks:

Medfusion

Hemophilia Preferred Care

225-mg dose

Curascript

US Bioservices

300-mg dose

Transcript

375-mg dose

Ship to:

Physician’s office

Patient’s home

Other __________________________

Dispense: __________

Diluent: 10-cc vial preservative-free Sterile Water for Injection, USP; Ancillary supplies: 3-cc syringes as needed for

reconstitution; 18-guage needles as needed for reconstitution; 25-guage needles as needed for administration

(Initial)

__________

Sharps container on an as-needed basis

(Initial)

I certify that Xolair

therapy for asthma is necessary for this patient, and I will be supervising the patient’s treatment accordingly. I acknowledge by

signing this form that the information contained within is correct, and I have complied with the Blue Cross & Blue Shield of Mississippi Medical Policy

as it exists at the time of this prescription. I also acknowledge that my records are subject to audit by Blue Cross & Blue Shield of Mississippi.

_______________________________________________________________________________

____________________________________

Prescriber Original Signature*

Date

BCBSMS Use Only

Approved PA# _______________

Denied

The Blue Cross & Blue Shield of Mississippi Omalizumab (Xolair) Medical Policy can be obtained at For any eligibility and benefit questions,

contact Pharmacy Customer Service at 1-800-551-5258 or 601-664-4998.

*Prior Authorization is a determination of medical necessity. It is not a guarantee of payment or that member’s contract will be in effect at the time services are rendered.

Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company,

*This form cannot be processed without prescriber’s signature.

BCBS 22073

Rev. 6/09

is an independent licensee of the Blue Cross and Blue Shield Association.