FEP Prolia Medical Review Request

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• Required *

• Enter Patient Information

• Drug Name: *
• Blue KC ID (Not SS#): *
  • i
  • i
  • i
• 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 *

• 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:*

• Is the patient receiving aromatase-inhibitor therapy? *

  *Examples include, but not limited to: anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin)
  
  • Yes
  • No

• Is the patient’s prostate cancer metastatic? *

  • Yes
  • No

• Is the patient receiving androgen deprivation therapy? *

  *Examples include, but not limited to: bicalutamide (Casodex), flutamide (Eulexin), nilutamide (Nilandron), leuprolide (Lupron Eligard), and goserelin (Zoladex)
  
  • Yes
  • No

• Has the patient experienced inadequate treatment response, intolerance, or contraindication to bisphosphonate therapy? *

  • Yes
  • No

• Does the physician agree to correct any pre-existing hypocalcemia, if present, before initiation of therapy? *

  • Yes
  • No

• Is the patient at high risk for bone fracture(s)? *

  • Yes
  • No

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

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