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Prior Authorization Poteligeo

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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:*

Drug Name/J-Code:*

For Mycosis Fungoides —

Has the patient has received at least one prior systemic therapy (e.g., extracorporeal photopheresis, oral retinoid [bexarotene capsules {Targretin®, generics}, tretinoin capsules, isotretinoin capsules {Amnesteem®, Claravis™, generics}, acitretin capsules {Soriatane®, generics}], interferons [Intron-A®/Pegasys® {interferon-alpha injection}, Actimmune® {interferon-gamma injection}], HDAC inhibitors [Zolinza® {vorinostat capsules}, Istodax® {romidepsin injection}], methotrexate, Adcetris® [brentuximab vedotin injection], cyclophosphamide tablets or injection, or Folotyn® [pralatrexate injection].

  • Yes
  • No

Poteligeo is prescribed by, or in consultation with, an oncologist or a dermatologist?

  • Yes
  • No

For Sezary Syndrome

Has the patient has relapsed or refractory Sézary Syndrome

  • Yes
  • No

The patient has received at least one prior systemic therapy (e.g., extracorporeal photopheresis, oral retinoid [bexarotene capsules {Targretin®, generics}, tretinoin capsules, isotretinoin capsules {Amnesteem®, Claravis™, generics}, acitretin capsules {Soriatane®, generics}], interferons [Intron-A®/Pegasys® {interferon-alpha injection}, Actimmune® {interferon-gamma injection}], HDAC inhibitors [Zolinza® {vorinostat capsules}, Istodax® {romidepsin injection}], methotrexate, or Adcetris® [brentuximab vedotin injection], cyclophosphamide tablets or injection, or Folotyn® [pralatrexate injection]).0

  • Yes
  • No

AND

Poteligeo is prescribed by, or in consultation with, an oncologist or a dermatologist?

  • Yes
  • No

Medications tried and failed: *

PLEASE SEND PROGRESS NOTES

If you are using a Specialty Pharmacy, please indicate which one will be providing the medication.*

  • Optum Specialty Services
    Phone: 855-427-4682
    Fax: 800-218-3221
  • Buy and Bill
  • Other:

If service is not in your office, please list the Infusion site or Facility/list ordering physician.

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

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Blue Cross and Blue Shield of Kansas City
Pharmacy Services
P.O. Box 412735
Kansas City, MO 64141-2735

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Revised 01/01/2020

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