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Oncotype DX Request Form for Breast Cancer PRESCRIBER INFORMATION PHYSICIAN NAME PROVIDER ID/TAX ID if out of state must have tax ID PATIENT S BCBSNC ID CONTACT PERSON/PRACTICE NAME PRACTICE PHONE PRACTICE ADDRESS PATIENT INFORMATION PATIENT NAME PRACTICE FAX PATIENT S DATE OF BIRTH CITY STATE ZIP DATE OF Breast Cancer DIAGNOSIS S3854 other codes BCBSNC will provide coverage for Oncotype DX when the criteria shown below are met. YES NO BCBSNC doe.

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Why is it used? Your specialist may recommend the Oncotype DX test if the benefit of chemotherapy for you is less clear. Chemotherapy may be given after surgery to reduce the risk of breast cancer coming back in future. Whether you're offered chemotherapy depends on a number of features of your breast cancer.

Recurrence Score of 0-25: The cancer has a low risk of recurrence. The benefits of chemotherapy likely will not outweigh the risks of side effects. Recurrence Score of 26-100: The cancer has a high risk of recurrence.

A score of 38 or lower means you have a low risk of cancer returning, and the risks of radiation treatments outweigh any benefits for you. A score between 39-54 means you're at medium risk and it's unclear if radiation will help. A score greater than 54 means you're at high risk of the cancer coming back.

Oncotype DX score is 26 or higher.

Recurrence Score of 16-20: The cancer has a low to medium risk of recurrence. The benefits of chemotherapy likely will not outweigh the risks of side effects. Recurrence Score of 21-25: The cancer has a medium risk of recurrence.

The Oncotype® and OncoExTra™ tests are covered by Medicare and many commercial insurance plans and available to patients who are enrolled in a Medicaid program.

A score of 26 or above means you're likely to benefit from having chemotherapy in addition to hormone therapy.

Table 3 ItemMean cost (USD)Oncotype DX test5141Endocrine therapy (years 1–5)256.5Endocrine therapy (years 6–8)289.6Chemotherapy14362 more rows • Jul 1, 2019

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  • micrometastases
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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232