Download Lupron Hormonal Therapy

Member Name: {{MEMFIRST}} {{MEMLAST}} DOB: {{MEMBERDOB}} PA Number: {{PANUMBER}}
Lupron Hormonal Therapy
Prior Authorization Request
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 1-866-249-6155. 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 Name:
Patient’s ID:
Physician’s Name:
Specialty: _________________________________,
Physician Office Telephone:
Date:
Patient’s Date of Birth:
NPI#: ___________________________
Physician Office Fax:
1.
Which drug and strength is being prescribed?
 Lupron Depot 7.5mg
 Lupron-PED Depot 7.5mg
 Lupron Depot 22.5mg
 Lupron-PED Depot 11.25mg
 Lupron Depot 30mg
 Lupron-PED Depot 15mg
 Lupron Depot 45mg
 Lupron-PED Depot 30mg
 Leuprolide (Leuprolide acetate, Lupron microdose, Lupron 2 week kit)
 Lupron Depot 3.75mg
 Lupron Depot 11.25mg
 Other ___________________________________
2.
What is Lupron being used for?
 Infertility
 Uterine fibroids
 Endometriosis
 Ovarian cancer
 Prostate cancer
 Breast cancer
 Treatment of children with central precocious puberty (CPP)
 Use as stimulation test to confirm diagnosis of central precocious puberty (CPP) 
 In combination with growth hormone for a child with growth failure and advancing puberty
 Other ___________________________________
3.
What is the ICD9? ________________
4.
What is the gender of the patient? If Male, skip to #7  Male  Female
5.
Does the patient have UNDIAGNOSED abnormal vaginal bleeding?  Yes  No
6.
Has pregnancy and breast feeding been excluded?  Yes  No
7.
Is the patient currently on therapy with Lupron?  Yes, Date started: ________________  No
Complete the section designated for the patient’s diagnosis
Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155
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 yo u have received the fax in error, please
immediately notify the sender by telephone and destroy the original fax message. Remodulin, Tyvaso, Ventavis SGM - 9/2012
CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062
Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com
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Member Name: {{MEMFIRST}} {{MEMLAST}} DOB: {{MEMBERDOB}} PA Number: {{PANUMBER}}
SECTION A: Central Precocious Puberty
8. Has the diagnosis been confirmed by a pubertal response to a GnRH agonist test?  Yes  No
9.
Has the diagnosis been confirmed by assessment of bone age versus chronological age?  Yes  No
10. Will discontinuation of therapy be considered at the appropriate timepoint for the onset of puberty? (i.e. 11
years of age for girls and 12 years of age for boys)  Yes  No
11. How old was the patient at the onset of secondary sexual characteristics? ________________ years
Complete questions 12-14 if the patient is not currently on therapy.
12. Has appropriate diagnostic imaging of the brain been done to exclude an intracranial tumor?  Yes  No
13. Have the following been evaluated? If Yes, select below  Yes  No  Not indicated
 Adrenal steroid levels to rule out congenital adrenal hyperplasia
 Appropriate diagnostic imaging to rule out steroid-secreting tumors
14. If the patient is a male and it is indicated, have beta human chorionic gonadotropin levels been evaluated to rule
out a chorionic gonadotropin secreting tumor?  Yes  No  Not indicated
SECTION B: Prostate Cancer
15. What is the patient’s current stage of prostate cancer?
 Clinically localized disease
 Locally advanced disease No further questions
 Recurrent disease No further questions
 Metastatic (regional lymph node/distant metastases) No further questions
16. Is Leuprolide or Lupron-Depot being used as neoadjuvant androgen deprivation therapy (ADT) for radical
prostatectomy?  Yes  No
17. Will Leuprolide or Lupron-Depot be used to shrink the large prostate to an acceptable size for brachytherapy?
If Yes, no further questions  Yes  No
18. Is Leuprolide or Lupron-Depot being used before, during or after radiation therapy?  Yes  No
19. What is the risk of cancer recurrence?  Low risk  Intermediate risk  High risk
SECTION C: Breast Cancer
20. Is the patient premenopausal?  Yes  No
21. Is the patient pregnant right now?  Yes  No
22. Is breast cancer hormone receptor positive?  Yes  No
23. Will leuprolide be used as an adjuvant therapy? If Yes, no further questions  Yes  No
24. Does the patient have metastatic or recurrent disease?  Yes  No
25. Will leuprolide be used in combination with endocrine therapy?  Yes  No
SECTION D: Infertility
26. Is Lupron being used to inhibit premature luteinizing hormone (LH) surge in controlled ovarian
hyperstimulation (COH)?  Yes  No
Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155
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 yo u have received the fax in error, please
immediately notify the sender by telephone and destroy the original fax message. Remodulin, Tyvaso, Ventavis SGM - 9/2012
CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062
Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com
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Member Name: {{MEMFIRST}} {{MEMLAST}} DOB: {{MEMBERDOB}} PA Number: {{PANUMBER}}
27. Is the patient pregnant right now?  Yes  No
SECTION E: Uterine Fibroids
28. Does the patient have a diagnosis of anemia? (e.g., Hct less than or equal to 30% and/or Hgb less than or equal
to
10 g/dL) Yes  No
29. Will Lupron Depot be used in conjunction with iron therapy?  Yes  No
SECTION F: Endometriosis
30. Has the patient received a total of two 6-month courses of Lupron Depot therapy for endometriosis? Yes
 No
31. Is the patient treatment naive to Lupron Depot therapy for endometriosis? If Yes, no further questions  Yes
 No
32. Has the patient had a recurrence of symptoms?  Yes  No
33. Will the patient be receiving add-back therapy (e.g., norethindrone) in addition to Lupron Depot?  Yes 
No
34. Has the patient been determined to have a bone mineral density within normal limits?  Yes  No
SECTION G: Ovarian Cancer
35. What is the tumor type?
  Ovarian stromal tumor
 Epithelial ovarian cancer
 Fallopian tube cancer

 Primary peritoneal cancer
 Other ___________________________________
36. Does the patient have relapsed stage II-IV granulosa cell tumors?
 Yes  No
37. Is the disease stable, recurrent, or persistent with primary chemotherapy?  Yes  No
38. Will Lupron Depot be used as a single agent?  Yes  No
Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155
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 yo u have received the fax in error, please
immediately notify the sender by telephone and destroy the original fax message. Remodulin, Tyvaso, Ventavis SGM - 9/2012
CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062
Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com
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Member Name: {{MEMFIRST}} {{MEMLAST}} DOB: {{MEMBERDOB}} PA Number: {{PANUMBER}}
Information given on this form is accurate as of this date:
X_______________________________________________________________________
Prescriber or Authorized Signature
Date (mm/dd/yy)
Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155
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 yo u have received the fax in error, please
immediately notify the sender by telephone and destroy the original fax message. Remodulin, Tyvaso, Ventavis SGM - 9/2012
CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062
Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com
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