State Sponsored Business, UniCare Health Plan of Kansas, Inc.

Neuropathic Pain Management Enrollment Form (Prialt®)

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Fax completed form to: CuraScript
Fax number: 1-866-545-0062 | Provider Services phone number: 1-888-662-0944
Part I Patient Information
Patient’s last name / First name / Middle initial
Address
City / State / ZIP code
Day phone number
( ) - / Night phone number
( ) - / Date of birth
/
Parent/Guardian / Allergies / Sex
M F
Primary insurance / Secondary insurance
Cardholder name (if not patient) / Cardholder name (if not patient)
Member ID and Group number / BIN# / Member ID and Group number / BIN#
Insurance phone number (+area code)
( ) - / Insurance phone number (+area code)
( ) -
Employer / Employer
Part II Physician Information (please supply copy of patient’s insurance card)
Prescriber’s name / Hospital/Clinic / Office contact name
Address
City / State / ZIP code
Phone number (+area code)
( ) - / Fax number (+area code)
( ) -
DEA number / NPI / UPIN
Patient’s Last Name: First Name: DOB: / /
Part III Medical Criteria (double click on the fields below to fill in this form electronically)
MEDICAL CRITERIA
Primary Diagnosis
Severe chronic neuropathic pain where continuous intrathecal (IT) infusion is warranted Date of Diagnosis //
Other:
Prior Therapy:
Yes No Has patient received previous treatment? If yes, drug(s) used and dates of therapy:
Drug: Date: / / Duration:
Drug: Date: / / Duration:
Drug: Date: / / Duration:
Drug: Date: / / Duration:
Drug: Date: / / Duration:
Patient Criteria:
Yes No Is the patient at least 18 years old?
Yes No Is the patient able to receive a continuous intrathecal infusion via a catheter using an external or internal implanted mechanical fusion pump?
Yes No Does the patient have a pre-existing history of psychosis?
Storage & Handling:
Store PRIALT at 20C-80C (360F-460F)
Once diluted aseptically with normal saline, PRIALT may be stored at 20C-80C for 24 hours
Do not freeze PRIALT
Protect from light
Prescription
Prialt®
100mcg/1mL vial 500mcg/5mL vial (100mcg/mL)
500mcg/20mL vial (25mcg/mL)
Dose: 2.4mcg/day INTRATHECALLY 2 times per week
2.4mcg/day INTRATHECALLY 3 times per week
Other:
Quantity:
28-day supply 84-day supply Other:
Refills:
1 Year 6 months Other:
Prescriber’s signature / Date
/ /
CuraScript is able to fill your request as written. Please provide the following information to expedite your order:
CuraScript to dispense (check box)
Ship medication to:
Physician Office Other Need by Date: : / /

*Confidentiality notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited.

UniCare Health Plan of Kansas, Inc. ®Registered mark of WellPoint, Inc. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.

0109 KSWX2400 11/11