) Injectable Medication Precertification Request

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MEDICARE FORM Prolia , Xgeva (denosumab) Injectable Medication Precertification Request Page 1 of 3For Medicare Advantage Part B: FAX: 1-844-268-7263 PHONE: 1-866-503-0857 For other lines of business: Please use other form. Note: Xgeva is non-preferred. The preferred product is pamidronate or zoledronic acid. Pamidronate and zoledronic acid do not require Precertification . (All fields must be completed and legible for Precertification review.) Please indicate: Start of treatment:Start date: / / Continuation of therapy:Date of last treatment / / Precertification Requested By: Phone: Fax: A. PATIENT INFORMATIONFirst Name: Last Name: DOB: Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: Email: Current Weight: lbsor kgsHeight: inchesor cms Allergies: B. INSURANCE INFORMATIONAetna Member ID #: Group #: Insured: Does patient have other coverage?

Is the patient receiving 1000mg of calcium and 400 international units of vitamin D daily? Yes . ... letrozole (Femara) Other: please identify: No. Yes. Is there documentation that the trial of oral and/or injectable bisphosphonates was ineffective? Please identify the failure of …

  Patients, Letrozole