State Sponsored Business, Anthem Blue Cross and Blue Shield

Tysabri® (natalizumab) Enrollment Form

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Fax completed form to: PrecisionRx Specialty Solutions
Fax number: 18668623170 | 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
Primary Diagnosis
Multiple Sclerosis (ICD-9 340) Type: Date of Diagnosis / /
Regional Enteritis (ICD-9 550.0-555.9) Date of Diagnosis / /
Other: Date of Diagnosis / /
Approval Criteria for Tysabri®:
Yes No Patient is 18 years of age or older
Yes No Patient has had a gadolinium-enhanced MRI scan of the brain and, when indicated, cerebrospinal fluid analysis to help differentiate potential future MS symptoms from PML as required by the FDA
Yes No Patient has had a trial and failure of at least one other treatment contraindicated to all treatments for MS (Avonex, Betaseron, Copaxone, Rebif)
Yes No Tysabri will be used as monotherapy
Yes No Patient is currently on other immune system modifying drugs such as antineoplastics, immunosuppressants or immunomodulators
Yes No Patient has a medial condition which significantly compromised the immune system Including HIV infection or AIDS, leukemia, or Lymphoma or organ transplant.
Yes No Patient has a current or prior history of progressive multifocal leukoencephalopathy (PML)
Patient’s Last Name: First Name: DOB: / /
Part III Medical Criteria (continued)
Yes No Patient has enrolled in and met all conditions of the TOUCH (Tysabri Outreach: Unified Commitment to Health) Prescribing Program
Yes No Patient has Crohn’s disease and has had an inadequate response or is unable to tolerate conventional therapies (sulfasalazine, mesalamine products, corticosteroids, immunosuppressants)
Yes No Patient has Crohn’s disease and has had inadequate response or is unable to tolerate Remicade and Humira
Yes No Tysabri will be used concomitantly with immunosuppressants (6-mercaptopurine, Azathioprine, cyclosporine, or methotrexate)
Yes No Is patient on chronic oral corticosteroids
Yes No If yes, will tapering begin as soon as therapeutic benefit of Tysabri has occurred? Yes No
Yes No Patient has been on Tysabri for 6 months. If yes, tapering has begun? Yes No
Yes No Patient has experienced therapeutic benefit by 12 weeks of induction of therapy
Yes No No Is patient on chronic oral corticosteroids
Yes No If yes, will tapering begin as soon as therapeutic benefit of Tysabri has occurred? Yes No
Yes No Patient has been on Tysabri for 6 months
Yes No If yes, tapering has begun
Yes No Patient has experienced therapeutic benefit by 12 weeks of induction of therapy
Tysabri® 300mg/15mL SDV Prescription:
300mg IV infusion over 1 hour every 4 weeks
Quantity: 15mL (1vial)
Day Supply: 28
Other:
Dose/Directions:
Quantity:
Day Supply: 28-day supply 84-day supply Other:
Supplies:
Sterile Water for Injection, 10cc vial, preservative free
3 cc Luer Lok Syringes
18 gauge, 1” needles
25 gauge, 5/8” needles
Sharps Container
Alcohol Pads
Refills:
1 Year 6 months Other:
Because of the risk of hypersensitivity, patients should be closely observed by a trained health care professional or a home health nurse for an appropriate period of time after Tysabri® administration. Patients should also be informed of the signs and symptoms hypersensitivity of and instructed to seek immediate medical attention should symptoms arise.
Prescriber’s signature / Date
/ /
PrecisionRx Specialty Solutions is able to fill your request as written. Please provide the following information to expedite your order:
PrecisionRx Specialty Solutions to dispense (check box)
Ship medication to:
Physician Office Other Need by Date: : / /

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