FEP Hyaluronic Acid Derivatives

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* Required Field

Enter Patient Information

  • Drug Name: *
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • ICD-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters along with decimals
    Codes must be 3 - 8 characters and 2 decimals.
  • Has the patient been using samples?
  • Yes No
  • Dose and Directions: *

* Required Field

Enter Provider Information

  • Provider ID OR NPI: *
  •   
  • Provider's Name: *
  • Physician's Specialty: *
  • Street Address: *
  • City: *
  • State: *
  • ZIP Code: *
  • Email Address:
  • Phone Number:
  • Enter a 10 digit phone number.
  • Fax Number:*
  • Enter a 10 digit phone number.
  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address: *
  • Contact Phone Number: *
  • Contact Phone Ext:
  • Contact Fax Number:*

1. What is the J-Code:

2. If Osteoarthritis (OA, DJD) what is the location?

  • Left knee only
  • Right knee only
  • Both knees *

3. Is this the INITIATION or CONTINUATION of therapy?

  • INITIATION
    1. Please list TWO or more conservative non-pharmacologic therapies tried: *
    2. Please specify what medications the patient failed to achieve an adequate response, has an intolerance or contraindication to (Check all that apply OR None of these):
      Acetaminophen
      Oral NSAIDs
      Topical NSAIDs
      Tramadol
      None of these *
    3. Has the patient had an inadequate response, intolerance, or contraindication to intra-articular steroid injections in which the efficacy lasted less than 8 weeks?
      • Yes
      • No *
    4. Is there radiologic confirmation of Kellgren-Lawrence score of grade 2 or greater?
      • Yes
      • No *
  • CONTINUATION (Renewal of PA)
    1. Is there documented improvement in pain with the previous course of treatment?
      • Yes
      • No *
    2. Has at least 12 months elapsed since the last injection of the prior treatment cycle?
      • Yes
      • No *
    3. Has there been a documented reduction of dosing of NSAIDs or other analgesics during the 12 month period following the last injection of the prior treatment cycle?
      • Yes
      • No *

If you have any additional information pertinent to this patient’s therapy, please specify.

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Or, print the form and mail to:

Blue Cross and Blue Shield of Kansas City
Pharmacy Services
P.O. Box 412735
Kansas City, MO 64141-2735

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Revised 12/28/16

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.