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This document is a prior authorization form for the medication Erivedge, intended for use by prescribers to request approval for insurance coverage for patients requiring this medication.
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How to fill out erivedge prior authorization form
How to fill out erivedge prior authorization form
01
Gather patient information such as name, date of birth, and insurance details.
02
Provide the prescribing physician's details including name, contact information, and NPI number.
03
Specify the diagnosis requiring treatment with Erivedge.
04
Include relevant medical history and prior treatments undertaken for the condition.
05
Fill in the dosage and proposed duration of treatment with Erivedge.
06
Attach any additional documentation or lab results that support the request.
07
Review the completed form for accuracy and completeness.
08
Submit the form to the appropriate insurance provider or review board.
Who needs erivedge prior authorization form?
01
Patients prescribed Erivedge (vismodegib) for the treatment of basal cell carcinoma.
02
Healthcare providers who are initiating treatment with Erivedge on behalf of their patients.
03
Insurance companies that require prior authorization before covering the cost of Erivedge.
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People Also Ask about
Does hair grow back after Erivedge?
All of the details of hair loss due to Erivedge vismodegib are not known. Hair usually starts to regrow after the treatment is completed, but could take months or longer to fully regrow. Accounts of incomplete or partial hair regrowth have been reported.
How long do you take Erivedge?
Talk to your doctor about how long you should 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.
What is the drug Erivedge used for?
Erivedge® (vismodegib) capsule is a prescription medicine used to treat adults with a type of skin cancer, called basal cell carcinoma, that has spread to other parts of the body or that has come back after surgery or that your healthcare provider decides cannot be treated with surgery or radiation.
How effective is Erivedge?
In 2 multicentered, phase II studies, tumor responded vismodegib therapy in 43% and 46% of patients with locally advanced basal cell carcinoma, and in 31% of patients with metastatic disease, with complete response rate in 21% of patients.
Is Erivedge an immunotherapy?
The main targeted drugs and immunotherapy for skin cancer are: () cream. cemiplimab (Libtayo) vismodegib (Erivedge)
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.
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What is erivedge prior authorization form?
The Erivedge prior authorization form is a document required by insurance companies to obtain approval for the use of Erivedge (vismodegib), a medication used to treat basal cell carcinoma.
Who is required to file erivedge prior authorization form?
Doctors or healthcare providers prescribing Erivedge on behalf of patients are required to file the Erivedge prior authorization form to ensure insurance coverage.
How to fill out erivedge prior authorization form?
To fill out the Erivedge prior authorization form, complete sections that include patient information, physician details, medical history, treatment plans, and any supporting documentation.
What is the purpose of erivedge prior authorization form?
The purpose of the Erivedge prior authorization form is to verify that treatment with Erivedge is medically necessary and to confirm that the patient's insurance will cover the medication costs.
What information must be reported on erivedge prior authorization form?
The information that must be reported on the Erivedge prior authorization form includes patient demographics, insurance details, diagnosis, treatment history, and physician information.
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