FEP Opdivo PA Request Form

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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:*

Has the patient been on Opdivo therapy continuously for the last 4 months, excluding samples?

NO – this would be the INITIATION of therapy, please answer the following questions for appropriate diagnosis:
Unresectable or Metastatic Melanoma
    1. Is the patient's BRAF V600 mutation positive or wild-type?
      • BRAF V600 mutation positive
      • BRAF V600 wild-type
      • Neither *
    2. * IF NEITHER, will the patient be using Opdivo in combination with ipilimumab (Yervoy)?
      • Yes
      • No *
  • Metastatic Non-Small Cell Lung Cancer
    1. Did the patient experience disease progression while on or after platinum-based chemotherapy?
      • Yes
      • No *
    2. Does the patient have an EGFR or ALK genomic tumor aberration?
      • Yes
      • No
    3. * If YES, has the patient experienced disease progression on FDA approved therapy?
      • Yes
      • No *
  • Advanced Renal Cell Carcinoma
    1. Has the patient had prior treatment with anti-angiogentic therapy?
      • Yes
      • No *
  • Relapsed or Progressed Classical Hodgkin Lymphoma
    1. Has the patient undergone autologous hematopoietic stem cell transplantation and post-transplantation therapy with brentuximab vedotin (Adcetris)?
      • Yes
      • No *
YES – this would be a PA renewal for CONTINUATION of therapy, please answer the following questions:
    1. Has the patient been assessed for immune-mediated adverse reactions?
      • Yes
      • No *
    2. Does the patient have any disease progression?
      • Yes
      • No *

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

Insert Attachments.

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  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please try again later.

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 12/29/16

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.