Download Lupron Hormonal Therapy

Lupron Hormonal Therapy
Prior Authorization Request
Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-855-330-1720
CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain
medications in order for the drug to be covered. To make an appropriate determination, providing the most accurate diagnosis for the use of the
prescribed medication is necessary. Please respond below and fax this form to CVS Caremark toll-free at 1-855-330-1720. If you have questions
regarding the prior authorization, please contact CVS Caremark at 1-866-814-5506. For inquiries or questions related to the patient’s eligibility, drug
copay or medication delivery; please contact the Specialty Customer Care Team: CaremarkConnect® 1-800-237-2767.
Patient’s Name: _____________________________
Date: ________________________________
Patient’s ID: _______________________________
Patient’s Date of Birth: ________________
Physician’s Name: _______________________________________________________________________
Specialty: _________________________________
NPI#: ________________________________
Physician Office Telephone: __________________
Physician Office Fax: ___________________
Approvals may be subject to dosing limits in accordance with FDA-approved labeling,
accepted compendia, and/or evidence-based practice guidelines.
Additional Demographic Information:
Patient Weight: _________________________kg
Patient Height:
ft
inches
Criteria Questions:
1. Which drug and strength is being prescribed?
 Lupron Depot 7.5 mg
 Lupron-PED Depot 7.5 mg
 Lupron Depot-3 month 22.5 mg
 Lupron-PED Depot 11.25 mg
 Lupron Depot-4 month 30 mg
 Lupron-PED Depot 15 mg
 Lupron Depot-6 month 45 mg
 Lupron-PED Depot 30 mg
 Lupron Depot 3.75 mg
 Leuprolide (Leuprolide acetate)
 Lupron Depot-3 month 11.25 mg
 Lupaneta Pack
 Other _____________________________________________
Indicate prescribed dose and frequency: _________________________________________________________
2.
What is the requested drug being used for?
 Infertility
 Uterine fibroids
 Endometriosis
 Ovarian cancer
 Prostate cancer
 Breast cancer
 Fallopian tube cancer
 Primary peritoneal cancer
 Central precocious puberty (CPP)
 Use as stimulation test to confirm diagnosis of central precocious puberty (CPP)
 Treatment of advancing puberty and growth failure
 Other _____________________________________________
3.
What is the ICD-10 code? _____________
4.
What is the patient's gender?  Female
5.
Does the patient have UNDIAGNOSED abnormal vaginal bleeding?  Yes  No  Not applicable
6.
Have pregnancy and breastfeeding been excluded?  Yes  No
 Male If Male, skip to diagnosis section.
Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended
recipient you hereby are advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received the fax in error, please
immediately notify the sender by telephone and destroy the original fax message. Lupron Hormonal SGM - 8/2016.
CVS Caremark is an independent company that provides pharmacy benefit management services to CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. members.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross
BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols
are registered trademarks of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
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Complete the following section based on the patient's diagnosis.
Section A: Central Precocious Puberty
7. What is the prescribed treatment schedule?
 1-month administration  3-month administration  Other ______________________________
8.
Is the patient currently receiving the prescribed therapy for central precocious puberty?
If Yes, no further questions  Yes  No
9.
Has the diagnosis of central precocious puberty been confirmed by a pubertal response to a GnRH agonist test or a
pubertal level of a third generation LH assay?  Yes  No ACTION REQUIRED: Attach documentation
of LH level from GnRH agonist test or a third generation LH assay.
10. Has the diagnosis been confirmed by assessment of bone age versus chronological age?  Yes  No
11. Has appropriate diagnostic imaging of the brain been done to exclude an intracranial tumor?  Yes  No
12. How old was the patient AT THE ONSET of secondary sexual characteristics? ________________ years
Section B: Prostate Cancer
13. Will the prescribed agent be used as neoadjuvant therapy prior to radical prostatectomy?  Yes  No
14. Does the patient have a lymph node-positive disease that was found during pelvic lymph node
dissection (PLND)?  Yes  No If No, skip to #17
15. Will the prescribed agent be used as adjuvant therapy?  Yes  No
16. Will the prescribed agent be used in combination with external beam radiation therapy (EBRT)?
 Yes  No If No, no further questions
17. What disease patient have:
 Metastatic  Regional  Recurrent  Progressive castration-naïve, no further questions
 None of the others, skip to #20
18. If metastatic or regional disease, will the prescribed agent be used as initial androgen deprivation therapy (ADT)?
 Yes  No No further questions
19. If recurrent disease, has the patient experienced biochemical failure after previous therapy?
 Yes  No No further questions
20. What is the disease’s risk stratification?  Very low  Low  Intermediate  High  Very High
21. Will the prescribed agent be used as initial ADT?  Yes  No
22. If very high, is the patient a candidate for definitive therapy? If Yes, skip to #24  Yes  No
23. If Intermediate or very high, will the prescribed agent be used in combination with EBRT?  Yes  No
24. If high or very high, what is the prescribed regimen?
 Prescribed agent + EBRT  Prescribed agent + EBRT + docetaxel  Other ___________________________
Section C: Breast Cancer
25. Is the patient premenopausal?  Yes  No
26. Is breast cancer hormone receptor positive?
 Yes  No
Section D: Infertility
27. Is leuprolide requested to prevent premature LH surges in a woman undergoing assisted reproductive technology
(ART) program? If Yes, document ART therapy patient is undergoing.  Yes  No
 In vitro fertilization (IVF)
 Gamete intra-fallopian transfer (GIFT)
 Zygote intra-fallopian transfer (ZIFT)
 Tubal embryo transfer (TET)
 Frozen embryo transfer (FET)
 Donor embryo cycles
 Other ________________________________
Section E: Uterine Fibroids
28. Has the patient received previous therapy with Lupron Depot or Lupaneta Pack?  Yes  No If No, skip to #31
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29. How long has the patient received prior therapy with Lupron Depot and Lupaneta Pack? _________ months
Document dates and doses received: ____________________________________________________________
__________________________________________________________________________________________
30. If less than 6 months of therapy received, has the patient been determined to have a bone mineral density within
normal limits?  Yes  No Document date of DEXA scan: ________________
31. Does the patient have a diagnosis of anemia?  Yes  No
Provide at least one lab value and date drawn:
Hematocrit (Hct): ________________ %
Date drawn: ________________
Hemoglobin (Hgb): ________________ g/dL
Date drawn: ________________
32. Will Lupron Depot be used in the preoperative setting to facilitate surgery?  Yes  No
33. Will Lupron Depot be used in conjunction with iron therapy?  Yes  No
Section F: Endometriosis
34. Has the patient received previous therapy with Lupron Depot or Lupaneta Pack?
 Yes  No If No, no further questions.
35. How long has the patient received previous therapy with Lupron Depot and Lupaneta Pack therapy? ______ months
Document dates and doses received: ____________________________________________________________
__________________________________________________________________________________________
36. If patient has received between 6 and 12 months of therapy, has the patient had a recurrence of symptoms?
 Yes  No  Not applicable, no further questions
37. Has the patient been determined to have a bone mineral density within normal limits?
 Yes  No Document date of DEXA scan: ________________
38. If Lupron Depot is being prescribed, will the patient be receiving add-back therapy (e.g., norethindrone) in addition
to Lupron Depot?  Yes  No
Section G: Fallopian Tube Cancer, Primary Peritoneal Cancer and Ovarian Cancer
39. If patient's diagnosis is ovarian cancer, what is the tumor type?
 Ovarian stromal tumor, No further questions
 Epithelial ovarian cancer
 Other _____________________________________________
40. Does the patient have persistent or recurrent disease?  Yes  No
41. Will Lupron Depot be used as a single agent?  Yes  No
Section H: Treatment of Advancing Puberty and Growth Failure
42. Is the patient a child with advancing puberty?  Yes  No
43. Is the patient also requesting OR is currently receiving growth hormone?  Yes  No
I attest that this information is accurate and true, and that documentation supporting this
information is available for review if requested by CVS Caremark or the benefit plan sponsor.
X_______________________________________________________________________
Prescriber or Authorized Signature
Date (mm/dd/yy)
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