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Anthem Blue Cross and Blue Shield State Sponsored Business Herceptin® (trastuzumab) Enrollment Form Fax completed form to: PrecisionRx Specialty Solutions Fax number: 1-866-862-3170 | Provider Services phone number: 1-888-662-0944 Part I Patient Information Patient’s last name First name Middle initial Address City Day phone number ( ) Parent/Guardian State Night phone number ( ) Allergies Date of birth / Primary insurance Secondary insurance Cardholder name (if not patient) Cardholder name (if not patient) Member ID and Group number BIN# Insurance phone number (+area code) ( ) Employer ZIP code / Sex M Member ID and Group number F BIN# Insurance phone number (+area code) ( ) Employer Part II Physician Information (please supply copy of patient’s insurance card) Prescriber’s name Hospital/Clinic Office contact name Address City Phone number (+area code) ( ) DEA number State Fax number (+area code) ( ) NPI ZIP code UPIN Part III Medical Criteria (double click on the fields below to fill in this form electronically) Primary Diagnosis (ICD9 Code) Yes No Patient is considered HER-2 positive if the BrCA is immunochemistry (IHC) 3+ or flourescent in situ hybridization (FISH) HER2 gene amplification + Yes No Patient is on neoadjuvant or adjuvant treatment regimens? Yes No Has patient undergone a cardiac assessment (MUGA or Echo)prior to initiation of therapy? Date: / / Yes No Was LVEF above the institutional lower limit of normal? Was LVEF competed at months 3, 6, and 9 of therapy? Please provide dates and LVEF. Month 3: Date: / / % Month 6: Date: / / % Month 9: Date: / / % Yes No The LVEF exhibited no more than 15% decrease in based on comparison to the baseline? Yes No Patient is on a metastatic regimen of treatment Please check the appropriate criteria: Yes No Drug is being used in a patient with metastatic breast cancer, as a single agent of in combination with chemotherapy, either in treatment naïve patients or in patients already receiving chemotherapy. Yes No Drug is being used as adjuvant therapy in a patient with lymph-node positive breast cancer Yes No Drug is being used as adjuvant therapy in a patient with lymph-node negative disease with a tumor measuring > 1 cm. Yes No Drug is being used as adjuvant therapy in a patient in the follow-up phase who completed adjuvant therapy if given within 6-12 months since completion of adjuvant chemotherapy. Yes No Drug is being used as neoadjuvant therapy for pre-operative case with locally advanced breast cancer. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. PrecisionRx Specialty Solutions is a pharmacy and department of NextRx, LLC. 0609 INW2392 06/05/09 State Sponsored Business, Anthem Blue Cross and Blue Shield Herceptin® (trastuzumab) Enrollment Form Page 2 of 2 Patient’s Last Name: First Name: DOB: / / Part III Medical Criteria (continued) Dosing: Patient Weight: lbs or kg Recommended Initial Loading Dose: 4 mg/kg IV as a 90 minute infusion Other: _____________________ Recommended Weekly Dose: 2mg/kg IV as a 30 min infusion Other: _____________________ Alternate dosing; 8 mg/kg IV as a 90 minute infusion 6 mg/kg IV every 3 weeks. Other: _____________________ Days Supply: Refills: 1 year Days 6 months Other: Supply List:: Sterile Water for Injection, 10cc vial, preservative free x 25 for every 3 weeks Sterile Water for Injection, 10cc vial, preservative free x 100 for every week 3 cc Luer Lok Syringes x1 for every 3 weeks 3 cc Luer Lok Syringes x4 for every week 18 gauge, 1” needles x1 for every 3 weeks 18 gauge, 1” needles x4 for every week 25 gauge, 5/8” needles x1 for every 3 weeks 25 gauge, 5/8” needles x4 for every week Sharps Container x1 Alcohol Pads x1 for every 3 weeks Alcohol Pads x4 for every week Prescriber’s signature Date / / PrecisionRx Specialty Solutions is able to fill your request as written. Please provide the following information to expedite your order: PrecisionRx Specialty Solutions to dispense (check box) Ship medication to: Physician Office Other Need by Date: : / / *Confidentiality notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited.