SERVICE REQUEST FORM KRYSTEXXAConnect

Patient:6. DIAGNOSIS AND THERAPY INFORMATION5. PRIOR AUTHORIZATION ASSISTANCE Please provide chart notes or other clinical information for PA INFUSION FACILITY INFORMATIONP rimary Diagnosis: Chronic Gout without tophi Chronic Gout with tophi Other Patient cannot take xanthine oxidase inhibitors due to contraindication or hypersensitivity reaction Patient s current oral treatment with xanthine oxidase inhibitors has failed to normalize serum uric acid and signs and symptoms are inadequately controlled despite receiving maximum medically appropriate dose of oral urate-lowering therapy (ULT)Gout medications previously tried and failed, with reason for discontinuation: (Provide the information below or include chart notes containing the required information.)

INDICATION AND IMPORTANT SAFETY INFORMATION. INDICATIONS AND USAGE. KRYSTEXXA ® (pegloticase) is indicated for the treatment of chronic gout in adult patients who have failed to normalize serum uric acid and

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