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

Xolair® (omalizumab) Enrollment Form

Page 3 of 3

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
Primary Diagnosis (ICD9 Code)
Secondary Diagnosis (ICD9 Code)
Patient Weight: lb / kg
Prior Therapy: Has patient received previous Xolair treatment: Yes, previously on therapy No, this is a Xolair naïve patient.
Other drug(s) used and dates of therapy for asthma treatment:
Drug: Date: / / Duration:
Drug: Date: / / Duration:
Patient’s Last Name: First Name: DOB: / /
Part III Medical Criteria (continued)
Approval Criteria for Xolair®:
Moderate to Severe Persistent Asthma:
Yes No Patient is 12 years of age or older
Yes No Patient has diagnosis of severe persistent asthma
Yes No Patient has continual symptoms, limited physical activity, and frequent exacerbations
Yes No Patient has frequent nocturnal symptoms
Yes No Patient has a (pre-treatment) FEV1 or PEF < 60% predicted
Yes No PEF variability is > 30%
Yes No Patient has diagnosis of moderate persistent asthma
Yes No Patient has daily symptoms; daily use of inhaled, short-acting, beta2-agonist; exacerbations affect activity; exacerbations are 2 times a week and may last for days
Yes No Patient has nocturnal symptoms which occur > 1 time a week.
Yes No Patient has a (pre-treatment) FEV1 or PEF of > 60% and < 80% predicted
Yes No PEF variability is > 30%
Yes No Patient has symptoms that are inadequately controlled with combination controller therapy (medium to high doses of inhaled corticosteroids plus long acting beta2-agonists or leukotriene modifiers) or cannot tolerate the medications
Yes No Patient shows a positive skin test or in vitro reactivity to a perennial aeroallergen
Yes No Patient has a Pre-Treatment FEV1 < 80% predicted
Yes No Patient has a serum IgE level equal to or greater than 30 IU/ml
Please provide pre-treatment serum IgE level: ______IU/ml
PRESCRIPTION
Xolair® Prescription: ***See Second Page for Dosing Guidelines***
150mg SQ every four weeks
300mg SQ every four weeks
225mg SQ every two weeks
300mg SQ every two weeks
375mg SQ every two weeks
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
EpiPen adult pediatric
Quantity:
28-day supply 84-day supply Other:
Refills:
1 Year 6 months Other:
Because of the risk of anaphylaxis, patients should be closely observed by a trained health care professional or a home health nurse for an appropriate period of time after Xolair® administration. Patients should also be informed of the signs and symptoms of anaphylaxis and instructed to seek immediate medical attention should symptoms arise.
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: : / /

DOSING GUIDELINES:

Xolair® (omalizumab)

Dosing based on pre-treatment serum IgE (IU/ml) and body weight (kg)

Administration of Xolair (mg) subcutaneously every FOUR weeks:

Pre-treatment Serum IgE (IU/ml) / Body Weight (kg)
30-60 / >60-70 / >70-90 / >90-150
30-100 / 150mg / 150mg / 150mg / 300mg
>100-200 / 300mg / 300mg / 300mg / See below
>200-300 / 300mg / See below / See below / See below
>300-400 / See below / See below / See below / See below
>400-500 / See below / See below / See below / See below
>500-600 / See below / See below / See below / See below
>600-700 / See below / See below / See below / See below

Administration of Xolair (mg) subcutaneously every TWO weeks:

Pre-treatment Serum IgE (IU/ml) / Body Weight (kg)
30-60 / >60-70 / >70-90 / >90-150
>100-200 / 225mg
>200-300 / 225mg / 225mg / 300mg
>300-400 / 225mg / 225mg / 300mg / Do not dose
>400-500 / 300mg / 300mg / 375mg / Do not dose
>500-600 / 300mg / 375mg / Do not dose / Do not dose
>600-700 / 375mg / Do not dose / Do not dose / Do not dose

*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 KSW2406 11/11