Prior Authorization Vyxeos

Vyxeos may be considered medically necessary in patients 18 years or older with therapyrelated acute myeloid leukemia or AML with myelodysplasia-related changes and if the conditions indicated below are met.

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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:*

Drug Name/J-Code: *

Member MUST have ONE of the following:

  • 1. Therapy-related acute myeloid leukemia. *
  • Yes
  • No
  • 2. Acute myeloid leukemia with Myelodysplasia-related changes. *
  • Yes
  • No

Member MUST have ALL of the following:

  • 1. Inadequate treatment response to the use of daunorubicin and cytarabine separately. *
  • Yes
  • No
  • 2. Prescriber agrees NOT to interchange with other daunorubicin and/or cytarabin containing products. *
  • Yes
  • No
  • 3. Prescriber agrees to do an electrocardiogram and assess cardiac function by multi-grated radionuclide angiography scan or schocardiography prior to administering Vyxeos. *
  • Yes
  • No

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
  • Other:
Select Optum or Other
Select Other Specialty Pharmacy

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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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 01/01/2020

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.

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