FEP Prolia Medical Review Request

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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:*
  • 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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  • 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.