Download Individual`s Name

REVIEW REQUEST FOR
Firmagon®, Zoladex®, Vantas®, Supprelin® LA, Lupron®, Eligard®, Trelstar®
(Gonadotropin Releasing Hormone Analogs)
Provider Data Collection Tool Based on Clinical Guideline DRUG-15
Complete form in its entirety and fax to:
CT: 203-985-6460 ME & NH: 603-695-7014
Policy Last Review Date: 05/10/2012
Request Date:
Initial Request
Buy and bill
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Policy Effective Date: 07/10/2012
Provider Tool Effective Date: 07/10/2012
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Subsequent Request
Individual’s Name:
Date of Birth:
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Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
ICD-9 Code(s) (if known):
Ordering Provider Name & Specialty:
Individual’s Weight
(lbs) (kg)
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering Provider):
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Place of Service:
Home
Office
Dialysis Center
Outpatient Hospital
Ambulatory Infusion
Ambulatory Infusion Center
Other:
Drug Name/HCPS Code (if known)
Dose to be administered:
Vantas®
®
Supprelin LA
Lupron®
®
Eligard
Trelstar®
®
Zoladex
Firmagon®
J1675
J1675
J1950
J9217
J3315
J9202
J9155
J9225
J9226
J9217
J9218
(mg)
J9218
Other:
When did the individual first start this drug?
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Duration:
(Weeks)
Please check all that apply to the individual:
Breast Cancer
Individual with hormone receptor positive breast cancer
Individual is pre-menopausal
Individual is peri-menopausal
Other
(Other)
Frequency (Days, Wks, Months)
Start Date For This Request:
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Ovarian Cancer
Individual with ovarian cancer (including fallopian tube cancer and primary peritoneal cancer)
Hormonal therapy for clinical relapse in individual with stage II-IV granulosa cell tumors
Hormonal therapy for treatment of epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer as a
single agent
Progressive, stable or persistent disease on primary chemotherapy
Relapse after complete remission following primary chemotherapy
Stage II-IV disease showing partial response to primary treatment
Low grade or focal recurrences after a disease free interval of greater than 6 months
Other
Prostate Cancer
Individual with prostate cancer
Clinically localized disease with intermediate (T2b to T2c cancer, Gleason score of 7, or PSA value of 10-20ng/mL)
or higher risk of recurrence
Locally advanced disease
Other advanced, recurrent, or metastatic disease
In combination with antiandrogen (flutamide or bicalutamide) for locally confined stage T2b-T4 (stage B2-C)
disease
To be used to shrink an enlarged prostate to an acceptable size prior to brachytherapy, cryosurgery or external beam
radiation therapy
Other
Central Precocious Puberty
Treatment of child known to have central precocious puberty (defined as beginning of secondary sexual characteristics
before age 8 in girls and 9 in boys)
Other
Gynecology Uses
Individual with chronic pelvic pain
Noncyclical pain lasting 6 or more months
Pain localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or
the buttocks
Pain is of sufficient severity to cause functional disability or lead to medical care
Request for continuation of treatment beyond 3 months
Individual has received symptomatic relief from prior treatment
Other
Individual with endometriosis
To induce amenorrhea in women in certain populations
Menstruating woman with severe thrombocytopenia
Menstruating woman with aplastic anemia
Other
Individual with dysfunctional uterine bleeding
Request for endometrial thinning prior to endometrial ablation for dysfunctional uterine bleeding
Preoperative treatment as adjunct to surgical treatment of uterine fibroids (leiomyoma uteri)
Will be used to reduce size of fibroids to allow for a vaginal procedure
Other
Prior to surgical treatment (myomectomy or hysterectomy) in individual with documented anemia
Other
Other Use(s) (Please submit all supporting documents including labs, progress notes, imaging, etc., for review.)
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This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
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Name & Title of Provider or Provider Representative Completing Form
Date
& attestation (Please Print)*
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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