Get the free Med D Zaltrap PAB Fax Form

This form is intended for healthcare providers to request prior authorization for the medication Zaltrap (ziv-aflibercept) for patients, including input fields for patient and physician information,

How to fill out med d zaltrap pab

How to fill out Med D Zaltrap PAB Fax Form

1. Obtain a copy of the Med D Zaltrap PAB Fax Form.
2. Fill out the patient's personal information in the designated fields, including name, date of birth, and insurance details.
3. Provide the prescribing physician's contact information, including name, phone number, and fax number.
4. Include the diagnosis and medical history relevant to the use of Zaltrap.
5. Indicate the prescribed dosage and treatment plan.
6. Attach any necessary supporting documentation, such as lab results or previous treatment records.
7. Review the form for completeness and accuracy.
8. Fax the completed form to the specified number on the form.

Who needs Med D Zaltrap PAB Fax Form?

1. Patients prescribed Zaltrap for cancer treatment who require prior authorization for their medication.
2. Healthcare providers looking to obtain medication coverage for their patients using Zaltrap.
3. Pharmacies needing to verify insurance approval before dispensing Zaltrap.

People Also Ask about

What is ZALTRAP used for?

ZALTRAP, in combination with , leucovorin, -(FOLFIRI), is indicated for the treatment of patients with metastatic colorectal cancer (mCRC) that is resistant to or has progressed following an oxaliplatin-containing regimen.

How much does ZALTRAP cost?

Zaltrap came to market in August at a price of about $11,000 a month. Soon after, Memorial Sloan-Kettering Cancer Center in New York decided not to use the drug, saying it was twice as expensive but no more effective than a similar medicine, from Genentech.

How long does a ZALTRAP infusion take?

ZALTRAP is administered through an intravenous (IV) infusion into your vein over approximately 1 hour. Administration of ZALTRAP is followed by a chemotherapy called FOLFIRI. ZALTRAP is usually given every 2 weeks.

What is the difference between ZALTRAP and ?

Aflibercept () is contraindicated in people with infections or active inflammations of or near the eye, while aflibercept (Zaltrap) has no contraindications.

What is the use of ZALTRAP injection?

ZALTRAP, in combination with , leucovorin, -(FOLFIRI), is indicated for the treatment of patients with metastatic colorectal cancer (mCRC) that is resistant to or has progressed following an oxaliplatin-containing regimen.

Is ZALTRAP chemotherapy or immunotherapy?

ZALTRAP is used together with chemotherapy. Tumors depend on new blood vessels to grow. Without these blood vessels providing nutrients and oxygen, the cancer cells cannot grow.

For pdfFiller’s FAQs

What is Med D Zaltrap PAB Fax Form?

The Med D Zaltrap PAB Fax Form is a document used for the pre-authorization process for Zaltrap (ziv-aflibercept) through Medicare Part D.

Who is required to file Med D Zaltrap PAB Fax Form?

Healthcare providers or pharmacies that prescribe or dispense Zaltrap under Medicare Part D are required to file the Med D Zaltrap PAB Fax Form.

How to fill out Med D Zaltrap PAB Fax Form?

To fill out the Med D Zaltrap PAB Fax Form, you need to provide patient information, prescribing healthcare provider details, and clinical information regarding the patient's condition and treatment plan.

What is the purpose of Med D Zaltrap PAB Fax Form?

The purpose of the Med D Zaltrap PAB Fax Form is to facilitate the approval process for Zaltrap under Medicare Part D, ensuring that the treatment is medically necessary and covered by the patient's insurance.

What information must be reported on Med D Zaltrap PAB Fax Form?

The information that must be reported includes patient demographics, insurance details, prescribing physician information, diagnosis, clinical notes, and previous treatment history.