Transcription of Keytruda® (pembrolizumab) Injectable Medication ...
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Keytruda® (pembrolizumab) Injectable Medication ...
GR-69035 (4-18)Keytruda (pembrolizumab) Injectable Medication Precertification Request Page 1 of 5 Aetna Precertification Notification503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX:1-888-267-3277 For Medicare Advantage Part B: FAX: 1-844-268-7263(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 : Address:City:State:ZIP:Home Phone: Work Phone: Cell Phone: DOB:Allergies:Email:Current Weight:lbs orkgsHeight:inches or cmsB.
First Name: Last Name: DOB: Address: City: ... (PD-L1) inhibitor (e.g., Opdivo (nivolumab), Tecentriq (atezolizumab), Keytruda (pembrolizumab), Bavencio (avelumab), or Imfinzi (durvalumab))? Yes . No . Is the requested drug prescribed for a pediatric patient with microsatellite instability-high (MSI-H) or tumor mutational burden-high (TMB-H ...
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