Download CARTA CIRCULAR #

CARTA CIRCULAR #M1302032
28 de febrero de 2013
A TODOS LOS HEMATÓLOGOS Y ONCÓLOGOS PARTICIPANTES DE TRIPLE-S SALUD
MEDICAMENTO: Dasatinib (Sprycel®)
A partir de la fecha de emisión de esta Carta Circular, si la cubierta de farmacia incluye
medicamentos de mantenimiento, Triple-S cubrirá el medicamento Dasatinib (Sprycel®) para
tratamiento de sus asegurados.
La política establecida en esta carta circular aplicará sólo a los participantes que inicien
tratamiento con este agente luego de la fecha de esta carta circular y que cumplan con los
siguientes criterios:
La receta tendrá que ser emitida por un hematólogo / oncólogo.
El paciente presenta uno de los siguientes diagnósticos:
o
Pacientes adultos con nuevo diagnóstico de Leucemia mielógena crónica (CML) en
fase crónica - Cromosoma Philadelphia positivo. ICD 9 (205)
o
Fase crónica, acelerada o mieloide o infoblástica – Cromosoma Philadelphia positivo
con resistencia o intolerancia a la terapia previa con imatinib. ICD 9 (205)
o
Leucemia linfoblástica aguda (ALL) – Cromosoma Philadelphia positivo con
resistencia o intolerancia a la terapia previa. ICD 9 (204)
El médico debe completar la forma que se adjunta y enviar con la receta.
Este cambio no aplica a los asegurados del Estado Libre Asociado de Puerto Rico (Mi
Salud).
Si necesita información adicional, comuníquese con nuestro Departamento de Relaciones
Profesionales al 787-749-4700 ó al 1-877-357-9777 (libre de cargos para llamadas de larga
distancia).
Cordialmente,
Dalia M. Graxirena, R.Ph
Gerente
Unidad de Operaciones
Zoraida Santos, R.Ph, MBA
Gerente
Unidad de Servicios Clínicos
Frank C. Astor Casalduc, MD, MBA, FACS
Director Médico Ejecutivo
División de Asuntos Médicos y Dentales
Ángela T. Hernández Michels,MD
Director Médico Asociado
División de Asuntos Médicos y Dentales
Anejo
Request Form for (dasatini [Sprycel®])
Pharmacy Department 787-774-4832 (Fax)
Physician Information
Name: _____________________________________________________________________________________________
# License: ________________________ Physician specialty: _________________________________________________
Address: ___________________________________________________________________________________________
Telephone: ______________________
Fax: _____________________________________________________________
Patient Information- General Information
Name: __________________________________
Date of birth: ______________________________________________
Sex: □ M
Member ID: _______________________________________________
□F
Weight:_________________
Address: ____________________________________________________________________________________________
Medical Information
1) Does the patient present with the following diagnosis :
□ Chronic Myelogenous Leukemia (CML)? Please answer questions #2 to #5
□ Philadelphia chromosome positive Acute Lymphoblastic Leukemia (ALL)? Please answer questions #6 and #7
2) If the patient presents with Philadelphia chromosome positive
chronic myelogenous leukemia, CML, what phase of the
disease does the patient present?
□ Chronic Phase
□ Accelerated Phase
□ Blastic phase
3) Does the patient have prior use of imatinib?
□ Resistance to imatinib therapy – Please provide
hematologic or cytogenetic test results.
□ Disease progression while on imatinib therapy –
Please provide hematologic or cytogenetic test
results.
□Yes □No
4) If yes, please provide previous treatment date?
Date ___________________________
5) After imatinib therapy, the patient presented:
□ Intolerance to imatinib therapy
6) If the patient presents Philadelphia chromosome positive
Acute Lymphoblastic Leukemia, please provide previous
therapy:
Drug______________________ Date ________
Drug ______________________ Date ________
7) After previous therapy, did the patient:
a. Present resistance? □Yes □No
b. Present intolerance? □Yes □No
Please provide any medical information which may support approval: (optional)
Physician signature:
Date:
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