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

Myozyme® (alglucosidase alfa) Enrollment Form

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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
Part III Medical Criteria (double click on the fields below to fill in this form electronically)
MEDICAL CRITERIA
Patient Weight: lb / kg
Select appropriate diagnosis below:
Glycogenosis (Pompe Disease, infantile onset) (ICD-9: 271.0) Date of Diagnosis: /
Other: ICD-9: Date of Diagnosis: /
Administration Site: Physician’s Office Infusion Center Patient’s Home Other:
Note: Risk of hypersensitivity reactions. Life-threatening anaphylactic reactions, including anaphylactic shock, have been observed in patients during Myozyme® Infusion. Because of the potential for severe infusion reactions, appropriate medical support measures should be readily available when Myozyme® is administered.
Patient’s Last Name: First Name: DOB: / /
Part III Medical Criteria (continued)
SUPPLIES
All Supplies:
Check here for pharmacy to dispense all needed supplies
Individual Supplies:
Sterile Water for Injection, 10 cc vial, preservative free Qty:
Syringes Qty:
10 cc Luer Lok
20 cc Luer Lok
Other:
Needles Qty:
18 gauge, 1”
25 gauge, 5/8”
Other:
Alcohol Pads Qty:
Sharps Container Qty:
Other: Qty:
PRESCRIPTION
Myozyme®
20mg/kg IV every 2 weeks over 4 hours
Other:
Sodium Chloride 0.9%
50 mL Bag
100 mL Bag
150 mL Bag
200 mL Bag
250 mL Bag
500 mL Bag
1000 mL Bag
Other:
Diphenhydramine 25mg capsules
25mg by mouth 60 minutes prior to Myozyme® IV therapy
Other:
Tylenol 8hr Tablets
1 tablet by mouth 60 minutes prior to Myozyme® IV therapy
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 KSW2398 11/11