Dosing & Administration Coding & Billing - PfizerPro

ELELYSO (taliglucerase alfa) for injectionStatement of Medical Necessity & Physician Order/Prescription Phone 1-855-ELELYSO (1-855-353-5976) Fax 1-866-758-7135Patient name (last, first) ________________________________________________________ DOB Gender: M FAddress _____________________________________________________ City __________________________________State_______ ZIP _____________Home phone ____________________________________ Work/cell phone ___________________________________ SS # _____________________________Description and ICD-9 and/or ICD-10 (include all that apply)ICD-9/272.7 ICD-10/E75.22 Other __________________________________________________________________________________________Method of diagnosis _____________________________________________ Date of diagnosis ____________________________________________Height _____ feet _____ inches Weight ______ lb kg (circle one)Allergies ___________________________________________________________________Hgb/Hct levels ______________________________________ Date _________________Platelets ___________________________________________ Date _________________Splenectomy: Complete Partial No Date ______________________________MRI: Yes No Date __________________Spleen volume ___________________ cc Normal: Yes No Times normal _________________Liver volume ____________________ cc Normal: Yes No Times normal _________________Other _________________________________________________________________________________________________________________Start date ___________________ Dosage change: Yes NoELELYSO (taliglucerase alfa) for injection__________ U/kg NDC 0069 0106 01Skeletal Hx:Avascular necrosisBone crisisBone painErlenmeyer flaskdeformityInfarction(s)Refills ___________________ Frequency _____________________Provide any medical supplies, including syringes and needles, as necessary to safely administer prescribed medicationsOther orders __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I certify that the therapy described above is medically necessary and that the information provided above is accurate to the best of my knowledge.I also attest that I have obtained the patient’s affirmative authorization to release the above information and such other personal information asmay be necessary to any other healthcare provider participating in their care/services. If the patient is 18 years of age or younger I attest that Ihave obtained permission from the patient’s legal guardian.Physician InformationName ______________________________________________________________________ Fax ______________________________________________Address _____________________________________________________________________ NPI # ____________________________________________Phone ______________________________________________________________________ DEA # ___________________________________________Physician signature ______________________________________ _________________________________________ Date ___________________Substitution permittedDispense as writtenNPE00870/TAL460203-01 © 2012 Pfizer Inc. All rights reserved Printed in USA/May 2012Joint replacementsLytic lesion(s)Marrow infiltrationOsteopeniaPathological Fx(s)NoneRD 5-01nDosing & Administration1. Dosing of ELELYSO (taliglucerase alfa) for injection 1■ The recommended dose is 60 Units/kg of body weight administered onceevery 2 weeks as a 60-120 minute intravenous infusion– Patients currently being treated with imiglucerase for Type 1Gaucher disease can be switched to ELELYSO– Patients previously treated on a stable dose of imiglucerase arerecommended to begin treatment with ELELYSO at that same dosewhen they switch from imiglucerase to ELELYSO■ Dosage adjustments can be made based on achievement and maintenance ofeach patient’s therapeutic goals2. Calculate number of vials used 1■ ELELYSO is supplied in a 200-Unit vial of sterile, nonpyrogenic, lyophilizedproduct for intravenous infusion. The number of vials needed for eachinfusion can be calculated as follows:Patient’s weight (kg)60 Units per kg200 (Units per vial)x÷=Number of vials(Round up to the next whole vial)– Vials of ELELYSO should be stored at 2ºC to 8ºC (36ºF to 46ºF).Keep out of light. Do not use after the expiration date on the vialTo start your patients on ELELYSO (taliglucerase alfa) for injection:Physician Certification Order/Prescription Medical Information Diagnosis Patient InformationSee Statement of Medical Necessity form on following pages.Or visit ELELYSOHCP.com to get more informationand download forms.Please see Important Safety Information on page 1 and full Prescribing Information on following pages.