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. PATIENT INFORMATIONF irst Name: Last Name: DOB: Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: Email: Current Weight: lbsor kgsHeight: inchesor cms Allergies: B. INSURANCE INFORMATIONA etna Member ID #: Group #: Insured: Does patient have other coverage?
(denosumab) Injectable Medication Precertification Request Page 3 of 3 (All fields must be completed and legible for precertification review.) 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 ...
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