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Office of Medical Assistance Programs FeeforService, Pharmacy Division Phone 18005378862 Fax 18663270191XOFIGO (radium ra223 dichloride) PRIOR AUTHORIZATION FORM Please submit all requested documentation
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Gather all necessary materials, including xofigo radium ra-223 dichloride, syringe, and sterile gloves.
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Who needs xofigo radium ra-223 dichloride?

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Xofigo radium ra-223 dichloride is used for the treatment of metastatic castration-resistant prostate cancer (mCRPC) with symptomatic bone metastases and no known visceral metastatic disease.
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Xofigo radium ra-223 dichloride is a medication used in the treatment of prostate cancer.
Medical professionals administering xofigo radium ra-223 dichloride are required to file relevant documentation.
To fill out xofigo radium ra-223 dichloride, medical professionals must provide relevant patient and treatment information.
The purpose of xofigo radium ra-223 dichloride is to treat prostate cancer and alleviate symptoms.
Information such as patient details, treatment dates, dosage, and side effects must be reported on xofigo radium ra-223 dichloride.
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