Get the free Erivedge (vismodegib) Prior Authorization Form

This document is used to collect necessary information for the prior authorization of Erivedge for patients diagnosed with basal cell carcinoma. It includes sections for prescriber information, member

How to fill out erivedge vismodegib prior authorization

How to fill out Erivedge (vismodegib) Prior Authorization Form

1. Obtain the Erivedge (vismodegib) Prior Authorization Form from your healthcare provider or the insurance company's website.
2. Fill out patient information including name, date of birth, and insurance details.
3. Provide the prescribing physician's information including name, contact number, and National Provider Identifier (NPI).
4. Indicate the prescribed medication (Erivedge) and the dosage.
5. Include the patient's diagnosis and relevant medical history that warrants the use of Erivedge.
6. Attach any necessary supporting documents such as medical records or previous treatment history.
7. Sign and date the form to authorize release of information to the insurance provider.
8. Submit the completed form to the insurance company via fax or online submission as instructed.
9. Follow up with the insurance company to confirm receipt and the status of the prior authorization request.

Who needs Erivedge (vismodegib) Prior Authorization Form?

1. Patients diagnosed with basal cell carcinoma (BCC) who require treatment with Erivedge (vismodegib).
2. Individuals who are starting treatment with Erivedge and need insurance approval for coverage.
3. Healthcare providers prescribing Erivedge on behalf of their patients.

People Also Ask about

Is Erivedge covered by insurance?

With the Genentech Oncology Co-pay Assistance Program, eligible patients with commercial insurance could pay as little as $0 per treatment for Erivedge. Co-pay assistance of up to $25,000 is provided per calendar year.

What is the difference between Erivedge and Odomzo?

Erivedge (Vismodegib): It works by selectively inhibiting the hedgehog pathway, thereby suppressing the growth of cancer cells. Odomzo (Sonidegib): Similar to Erivedge, Odomzo inhibits the hedgehog pathway, blocking signals that drive the uncontrolled growth of cancer cells.

What is the success rate of Erivedge?

Primary analysis: 9 months minimum follow-up* Independent review5† Complete response 20.6% (n=13) 0% (n=0) Partial response 22.2% (n=14) 30.3% (n=10) Median DOR (months) 7.6 7.6 (95% CI) (5.7-9.7) (5.6-NE)3 more rows

How much does Erivedge cost?

COST AND AVAILABILITY Genentech has set the price of vismodegib at $7,500 for a month's supply of once-daily capsules––or approximately $250 per capsule.

How long can you take Erivedge?

It's recommended that you continue taking Erivedge as long as it's working for you and your side effects are tolerable. Your doctor will perform certain tests to check you for side effects before and during treatment with Erivedge.

Is there a generic for Erivedge?

Is there a generic version of Erivedge available? No.

For pdfFiller’s FAQs

What is Erivedge (vismodegib) Prior Authorization Form?

The Erivedge (vismodegib) Prior Authorization Form is a document required by insurance providers to approve coverage for the medication Erivedge, which is used to treat certain types of basal cell carcinoma. This form ensures that the treatment is medically necessary before the insurance company will provide coverage.

Who is required to file Erivedge (vismodegib) Prior Authorization Form?

Healthcare providers, including physicians or healthcare practitioners who prescribe Erivedge (vismodegib), are required to file the Prior Authorization Form with the patient’s insurance company to obtain authorization for the medication.

How to fill out Erivedge (vismodegib) Prior Authorization Form?

To fill out the Erivedge (vismodegib) Prior Authorization Form, healthcare providers must include patient information, the diagnosis justifying the need for treatment, previous treatments attempted, expected duration of treatment, and any relevant medical history. Additional documentation may also be required to support the application.

What is the purpose of Erivedge (vismodegib) Prior Authorization Form?

The purpose of the Erivedge (vismodegib) Prior Authorization Form is to ensure that the prescribed treatment is appropriate and medically necessary, allowing insurance companies to evaluate the request for medication coverage based on established criteria.

What information must be reported on Erivedge (vismodegib) Prior Authorization Form?

The information that must be reported on the Erivedge (vismodegib) Prior Authorization Form includes the patient's personal information, diagnosis, previous therapies, treatment plan, and any supporting medical documentation that substantiates the need for Erivedge.