Download Provider Bulletin: [Subject]

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: :
/
/
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