Insurance Verification and Prior Authorization Form ...

Prolia 60 mg pre-filled syringe, 60 mg SC every 6 months Refill: x1 x2 x3 x4 Prescriber Signature: (required for legal prescription triage) _____Date: _____Patient s Scheduled Injection Date: (Age-related osteoporosis without current pathological fracture) _____ (Age-related osteoporosis with current pathological ) Please provide complete code Other (specify ICD Code) _____ Please provide secondary ICD Code, if applicable: _____ Original Diagnostic T-Score: _____ T-Score Date: _____ History of osteoporotic fracturePrior Osteoporosis Therapy (if any): Generic alendronate Fosamax (alendronate sodium) Actonel (risedronate sodium) Boniva (ibandronate sodium) Other _____Reason for Discontinuing Previous Osteoporosis Therapy(ies):_____Contraindications (if any):_____Patient is currently taking calcium and vitamin D supplements: Ye s NoCalcium level available: Ye s NoOther pertinent information: _____ The sample diagnosis codes are informational and not intended to be directive or a guarantee of reimbursement and include potential codes that would include FDA approved indications for Prolia.

Fax with copies of insurance card(s), front and back, to Amgen Assist®: 1-877-877-6542 *Asterisk fields are required for processing. If you have any questions, please contact Amgen Assist ® at 1-866-AMG-ASST (1-866-264-2778).

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