2011_Amgen Enbrel Formulary Win - OBC Campaign Prime Therapeutics
Name: 


A red asterisk (*) indicates required questions.

  1. (Call Pre-Work- Copy of Paste from Spreadsheet). CMA ID # ?*


  1. (Call Pre-Work- Copy of Paste from Spreadsheet). Telephone Number?*


  1. (Call Pre-Work- Copy of Paste from Spreadsheet). Prescriber Name: First and Last?*


  1. Please identify the state you are calling:*
    Alabama
    Alaska
    Arizona
    Arkansas
    California
    Colorado
    Connecticut
    Delaware
    District of Columbia
    Florida
    Georgia
    Hawaii
    Idaho
    Illinois
    Indiana
    Iowa
    Kansas
    Kentucky
    Louisana
    Maine
    Massachusetts
    Michigan
    Minnesota
    Mississippi
    Missouri
    Montana
    Nebraksa
    Nevada
    New Hampshire
    New Jersey
    New Mexico
    New York
    North Carolina
    North Dakota
    Ohio
    Okalahoma
    Oregon
    Pennsylvania
    Maryland
    Rhode Island
    South Carolina
    South Dakota
    Tennessee
    Texas
    Utah
    Vermont
    Virginia
    Washington
    West Virginia
    Wisconsin
    Wyoming
    Puerto Rico


  1. Is this our first attempt to contact the MDO*
    Yes
    No (Left message for return call)


  1. Was the office contact available to talk?*
    Yes
    No (second attempt scheduled)


  1. (Skip if contact is available to talk)- What is the preferred time for follow-up? Any specific day requested? "You should receive a follow-up within 2 business days"


  1. Were you aware of the recent changes with Prime Therapeutics?
    Yes
    No


  1. Did you receive a letter from Prime Therapeutics regarding the formulary changes?
    Yes
    No


  1. Are you familiar with the Enbrel Support Suite of Services?
    Yes
    No


  1. Do you currently have patients on Enbrel?
    Yes
    No


  1. Would you like our assistance in completing the exceptions/statement of medical necessity process for your Enbrel patient enrolled in Prime Therapeutics?
    Yes We will have your Single point of contact, Your Enbrel Access Specialist contact you directly
    No


  1. (If the MD wants a sample of the Insurance Verication/Prior Authorization Form) Did you fax it to them?
    Yes
    No, they don't need one.