Prior Authorization Form - Prolia/xgeva
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1Today’s date: __________________________________
Date medication needed: ___________________________
®
®
Prior Authorization Form – Prolia
/ Xgeva
ONLY COMPLETED REQUESTS WILL BE REVIEWED.
®
®
Select one:
Prolia
Xgeva
Check one:
New start
Continued treatment
Patient information (please print)
Physician information (please print)
Patient name
Prescribing physician
Address
Office address
City, state, ZIP
City, state, ZIP
Patient telephone #
Office contact
Patient ID
Office telephone #
Date of Birth
Fax #
NPI
No delivery requested; physician will use office supply. Authorization only.
Delivery requested to the physician’s office.
** A copy of the prescription must accompany the medication request for delivery.**
1)
Diagnosis for drug requested (must include ICD-10):
2)
Patient medical information
a.
T-score (required; include date of most recent measurement)
b.
Does the patient have a history of osteoporotic non-collision fracture (e.g., vertebral, hip, nonvertebral)?
Yes
No
c.
Does the patient have multiple risk factors for fracture (e.g., endocrine disorders; gastrointestinal
Yes
No
disorders; use of medications associated with low bone mass or bone loss, such as corticosteroids)?
d.
Does the patient have documented bone metastases from a solid tumor?
Yes
No
e.
Does the patient have a history of any of the following? (check all that apply)
Yes
No
Documented history of failure, contraindication, or intolerance due to side effects to at least one other
osteoporosis medicine (e.g., oral bisphosphonates, calcitonin, estrogens);
Documented inadequate response to at least one other osteoporosis medicine (e.g., oral
bisphosphonates; estrogens) after a 12-month trial;
Severely deteriorated condition such that the osteoporosis is so significant that a trial of oral
bisphosphonates is not medically warranted;
Receiving adjuvant aromatase inhibitor therapy for breast cancer with
(list drug);
Receiving androgen deprivation therapy for nonmetastatic prostate cancer with
(list drug);
Giant cell tumor of the bone, which is either unresectable or in a location where surgical resection is likely to result in
severe morbidity.
3)
Prescription Information:
Quantity
Refill x
month(s)
Instructions (include dose)
Every
day(s)/ week(s)/ month(s)
Physician’s Signature:
Please fax this completed form to 215-761-9580.
10/01/2015 #08.00.94
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and
with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
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