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This document is a request form for prior approval of prescription drugs, specifically for ICLUSIG (ponatinib). It requires information from both the cardholder and the prescribing physician to process
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How to fill out iclusig csu fax form
How to fill out Iclusig CSU Fax Form
01
Obtain the Iclusig CSU Fax Form from the official website or healthcare provider.
02
Fill in the patient’s personal information, including name, date of birth, and contact details.
03
Provide relevant medical history and treatment details as required on the form.
04
Write down the prescribing physician's information, including their name and contact number.
05
Include the patient's insurance details, if applicable.
06
Sign and date the form in the designated section.
07
Double-check all information for accuracy.
08
Fax the completed form to the appropriate contact number provided on the form.
Who needs Iclusig CSU Fax Form?
01
Patients prescribed Iclusig (ponatinib) for the treatment of certain types of leukemia.
02
Healthcare providers managing the treatment for patients who require prior authorization or assistance with coverage.
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People Also Ask about
How much does Iclusig cost?
Iclusig has a list price of $20,831 for 30 tablets. The FDA has granted an accelerated approval for a supplemental indication for Iclusig (ponatinib). It is now approved to treat adult patients who have been newly diagnosed with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL).
What is the drug Iclusig used for?
ICLUSIG is a prescription medicine used to treat adults who have: in combination with chemotherapy in newly diagnosed Ph+ ALL* alone in adults with Ph+ ALL who cannot receive any other kinase inhibitor medicines or who have a specific type of abnormal gene (T315I-positive) Ph+ ALL. Chronic Myeloid Leukemia (CML)
What is ponatinib 15 mg used for?
Ponatinib is used to treat certain types of chronic myeloid leukemia (CML; a type of cancer of the white blood cells), including treatment in people who can no longer benefit from other medications for CML or who cannot take these medications because of side effects.
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What is Iclusig CSU Fax Form?
The Iclusig CSU Fax Form is a document used to facilitate the communication between healthcare providers and the pharmaceutical company regarding the management of patients prescribed Iclusig (ponatinib) therapy.
Who is required to file Iclusig CSU Fax Form?
Healthcare providers who are prescribing Iclusig to their patients are required to file the Iclusig CSU Fax Form as part of the treatment management process.
How to fill out Iclusig CSU Fax Form?
To fill out the Iclusig CSU Fax Form, healthcare providers should accurately complete all required fields including patient information, prescribing physician details, and specific treatment information, then fax the completed form to the designated number provided by the pharmaceutical company.
What is the purpose of Iclusig CSU Fax Form?
The purpose of the Iclusig CSU Fax Form is to ensure proper documentation and communication regarding patient treatment, safety monitoring, and adherence to prescribing guidelines for Iclusig therapy.
What information must be reported on Iclusig CSU Fax Form?
The information that must be reported on the Iclusig CSU Fax Form includes the patient's name, date of birth, medical history, the prescribing doctor's details, treatment plan, and any relevant laboratory results or observations associated with the use of Iclusig.
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