Transcription of ) Injectable Medication Precertification Request
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) Injectable Medication Precertification Request
MEDICARE FORM Prolia , Xgeva (denosumab) Injectable Medication Precertification Request Page 1 of 3 For 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.
Giant cell tumor of the bone / / - / / Prevention of skeletal-related events in patients with multiple myeloma . Treatment of hypercalcemia of malignancy . Yes . Has the patient been treated with intravenous bisphosphonate therapy? Please indicate the date range of therapy: ...
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