FEP Xgeva 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:*

• Bone tumor

• 1. Does the patient have giant cell tumor of the bone? *
     
     • Yes
     • No
  2. Is the cancer unresectable or is surgical resection not recommended? *
     
     • Yes
     • No
  3. Does the physician agree to correct any pre-existing hypocalcemia prior to therapy? *
     
     • Yes
     • No
  4. Does the patient have a concurrent diagnosis of multiple myeloma? *
     
     • Yes
     • No

• Bone metastases

• 1. Does the patient have bone metastases from solid tumors? *
     
     • Yes
     • No
  2. Is the patient at high risk for skeletal-related events? *
     
     • Yes
     • No
  3. Has the patient experienced inadequate treatment response, intolerance, or contraindication to ONE of the following? *
     
     • IV Bisphosphonate
     • Pamidronate
     • Zoledronic acid
     • None of the choices
  4. Does the patient have a concurrent diagnosis of multiple myeloma? *
     
     • Yes
     • No

• Hypercalcemia

• 1. Does the patient have hypercalcemia of maliganancy? *
     
     • Yes
     • No
  2. Has the patient’s disease relapsed or progressed after biphosphate therapy? *
     
     • Yes
     • No

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

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