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Blue Cross Blue Shield of Michigan Medicare Advantage Medication Authorization Request Form (Aflibercept) HOPES CODE: J0178 or () HOPES CODE:J2778 or (Pegaptanib) HOPES CODE: J2503 This form is to
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How to fill out aflibercept or or pegaptanib
How to fill out aflibercept or or pegaptanib
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To fill out aflibercept or pegaptanib, follow these steps:
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- Wash your hands thoroughly with soap and water.
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- Take the vial of aflibercept or pegaptanib out of the refrigerator and allow it to warm to room temperature for about 15-30 minutes.
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- Inspect the vial for any signs of damage or discoloration. Do not use if the vial is damaged.
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- Use an alcohol wipe to clean the rubber stopper of the vial.
06
- Prepare a clean, well-lit work surface.
07
- Take the syringe and remove the needle cap.
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- Pull back the plunger to draw in air equal to your prescribed dose.
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- Insert the needle through the rubber stopper of the vial and push the plunger to inject air into the vial.
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- Turn the vial and syringe upside down and slowly draw out the prescribed dose of aflibercept or pegaptanib.
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- Remove any air bubbles by gently tapping the syringe and pushing the plunger slightly to eject the air.
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- Remove the needle from the vial and replace the needle cap.
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- Administer the medication as instructed by your healthcare provider.
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- Dispose of the used syringe and vial properly.
15
- Wash your hands again after handling the medication.
Who needs aflibercept or or pegaptanib?
01
Aflibercept or pegaptanib are medications used to treat certain eye conditions, such as age-related macular degeneration (AMD) and macular edema.
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These medications are typically prescribed for individuals who have been diagnosed with these conditions by an eye care professional.
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The decision to use aflibercept or pegaptanib will be based on various factors including the severity of the condition, the individual's medical history, and the healthcare provider's judgment.
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It is important to consult with an eye care professional to determine if aflibercept or pegaptanib is appropriate for your specific situation.
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