FEP Opdivo PA Request Form

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  • Required *

  • Enter Patient Information

  • Diagnosis Codes must be 3-8 characters along with decimals

    Codes must be 3 - 8 characters and 2 decimals.
  • Yes No
  • Required *

  • Enter Provider Information

  • Enter a 10 digit phone number.
  • Enter a 10 digit phone 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.

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