Lumizyme and Myozyme
Prior Authorization Form/ Prescription
Date: ___________ Date Medication Required:____________
Ship to:  Physician  Patient’s Home  Other __________
Phone: (855) 304-5580 Fax: (855) 521-1728
Patient Information
Last Name:
First Name:
Middle:
Address:
DOB: ____/____/_____
City:
Daytime Phone:
State:
Evening Phone:
Sex:
Male
Zip:
Female
Insurance Information (Attach Copies of cards)
Primary Insurance:
Secondary Insurance:
ID #
Group #
ID #
Group #
City:
State:
City:
State:
Physician Information
Name:
Specialty:
Address:
Phone # (
NPI:
City:
)
Secure Fax #: (
State:
)
Zip:
Office contact:
Prescription Information
MEDICATION
STRENGTH
DIRECTIONS
QUANTITY
REFILLS
Lumizyme
Myozyme
Primary Diagnosis
Primary ICD-9/ICD-10 Code: ___________________________
Pompe Disease
Other: __________________________________________
Clinical Information
INITIAL THERAPY
***** Please submit supporting clinical documentation*****
CONTINUATION OF THERAPY;
Therapy start date: __________________________
1. How was the diagnosis confirmed? Indicate all that apply, or mark "None of the above"
Acid a-glucosidase (GAA) assays confirming low acid a-glucosidase (GAA) activity
Acid a-glucosidase (GAA) activity testing in fibroblast
DNA testing for acid a-glucosidase (GAA) mutation
None of the above
2. In case of anaphylaxis, severe allergic reaction, or acute cardiorespiratory failure, will appropriate
medical support be readily available when the drug is administered?
Yes
No
3. Does the patient have evidence of cardiac hypertrophy?
Yes
No
Lumizyme
4. Does the patient have infantile-onset Pompe disease?
Yes
No
Myozyme
5. Does the patient have late (non infantile-onset) Pompe disease?
Physician’s Signature ________________________________________________ Date: ________________________
DAW