Download Fax Form - Caremark

Avastin
HMSA - 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 1-866-237-5512. If you have questions
regarding the prior authorization, please contact CVS Caremark at 1-808-254-4414. 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: ________________
Patient’s Phone Number: _______________________________
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. Indicate where the drug is being administered:
 Ambulatory surgical  Home  Inpatient hospital  Office  Outpatient treatment center  Pharmacy
2.
What is the ICD-10 code? __________________
3.
Will Avastin be administered by intravitreal injection for an ophthalmic disorder?  Yes  No If No, skip to #5
4.
What is the diagnosis? Indicate below and no further questions
 Choroidal neovascularization (CNV) associated with high (pathologic) myopia, ocular histoplasmosis syndrome,
angioid streaks, inflammatory conditions, or idiopathic
 Wet age-related macular degeneration (AMD) (including polypoidal choroidopathy and retinal angiomatous
proliferation subtypes of AMD)
 Macular edema due to retinal vein occlusion (RVO)
 Diabetic macular edema 

 Ocular neovascularization (choroidal, retinal, iris) associated with proliferative diabetic retinopathy
 Neovascular glaucoma, as adjunct
 Retinopathy of prematurity
 Other _______________________________
5.
What is the specialty of the practitioner who recommended Avastin?
 Oncologist
 Other _______________
Send completed form to: CVS Caremark Specialty Programs. Fax: 1-866-237-5512
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. Avastin HMSA 5/2017.
CVS Caremark Specialty Programs ● 2969 Mapunapuna Place ● Honolulu, HI 96819
Phone: 1-808-254-4414 ● Fax: 1-866-237-5512 ● www.caremark.com
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6.
What is the prescribed regimen?
 Avastin monotherapy
 Avastin + paclitaxel
 Avastin + cisplatin + paclitaxel
 Avastin + topotecan + paclitaxel
 Avastin + irinotecan
 Avastin + carmustine
 Avastin + lomustine
 Avastin + temozolomide
 Avastin + liposomal doxorubicin
 Avastin + topotecan
 Avastin + interferon alfa-2
 Avastin + carboplatin + paclitaxel
 Avastin + carboplatin + gemcitabine
 Avastin + cisplatin-based regimen
 Avastin + carboplatin-based regimen
 Avastin + pemetrexed 
 Avastin + FOLFIRI
 Avastin + FOLFOX
 Avastin + CapeOX
 Avastin + FOLFOXIRI
 Avastin + Xeloda (capecitabine)
 Avastin + 5FU + leucovorin
 Avastin + infusional 5-FU + leucovorin
 Avastin + irinotecan + oxaliplatin
 Avastin + pemetrexed +cisplatin
 Other ______________________
Key: FOLFIRI = leucovorin, fluorouracil, and irinotecan; FOLFOX = leucovorin, fluorouracil, and oxaliplatin; CapeOX
= capecitabine and oxaliplatin FOLFOXIRI = leucovorin, fluorouracil, oxaliplatin, and irinotecan
7.
What is the diagnosis?
 Breast Cancer
 Central Nervous System (CNS) Cancer
 Ovarian Cancer
 Soft Tissue Sarcoma
 Colon Cancer
 Rectal Cancer
 Cervical Cancer
 Endometrial Cancer
 Renal Cell Carcinoma
 Non-Small Cell Lung Cancer (NSCLC)
 Malignant pleural mesothelioma
 Other _______________________________
8.
Is this request for a new start or continuation of Avastin therapy?
If New Start, skip to diagnosis section  New Start  Continuation
9.
Was Avastin previously authorized by HMSA/CVS for this member?
 Yes  No If No, skip to diagnosis section
10. Is there any evidence of disease progression? Action Required: Please attach documentation including clinical
notes and objective findings such as imaging studies that demonstrate lack of disease progression on therapy.
(For colorectal cancer: both imaging studies and CEA levels will be evaluated but imaging studies will supersede
CEA levels when determining disease progression.)
 Yes – Colorectal cancer, skip to #47
 Yes – Not colorectal cancer, no further questions
 No, no further questions
Complete the following section based on the member’s diagnosis.
Section A: Breast Cancer
11. Is the disease recurrent or metastatic?  Yes  No
12. What is the member’s HER2 status? Action Required: Please attach documentation of HER2 status test result.
 Positive  Negative  Unknown
13. Does the member have symptomatic visceral disease? If Yes, no further questions  Yes  No
14. Does the member have visceral crisis? If Yes, no further questions  Yes  No
15. What is the member’s hormone receptor (HR) status? Action Required: Please attach documentation of HR status
test results.
 Positive
 Negative, no further questions
 Unknown
Send completed form to: CVS Caremark Specialty Programs. Fax: 1-866-237-5512
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. Avastin HMSA 5/2017.
CVS Caremark Specialty Programs ● 2969 Mapunapuna Place ● Honolulu, HI 96819
Phone: 1-808-254-4414 ● Fax: 1-866-237-5512 ● www.caremark.com
Page 2 of 5
16. Is the member refractory to endocrine therapy? Action Required: Please attach documentation with previous
treatment history.  Yes  No
Section B: Cervical Cancer
17. Is the disease persistent, recurrent or metastatic?  Yes  No
Section C: CNS Cancer
18. What is the tumor type of CNS cancer?
 Glioblastoma
 Anaplastic glioma
 Adult intracranial and spinal ependymoma (excludes subependymoma), skip to #20
 Other _________________
19. Is Avastin being used for recurrent or progressive disease?  Yes  No No further questions
20. Is Avastin being used for disease progression?  Yes  No
Section D: Endometrial Cancer
21. Has the disease progressed on prior cytotoxic chemotherapy?  Yes  No
Section E: Ovarian Cancer
22. What is the subtype of ovarian cancer?
 Epithelial ovarian cancer
 Primary peritoneal cancer
 Other ________________________
 Fallopian tube cancer
 Malignant sex cord-stromal tumors, skip to #25
23. Is the disease persistent or recurrent?  Yes  No
24. Has the member received Avastin in the past for persistent or recurrent disease?  Yes  No
25. Does the member have stage II-IV granulosa cell tumors?  Yes  No
26. Has the member had clinical relapse?  Yes  No
Section F: Renal Cell Carcinoma
27. In what clinical setting is Avastin being used?
 For relapse  For metastatic or stage IV disease  Other ________________________
28. What is the histology of the disease? Action Required: Please attach documentation on tumor histology.
 Non-clear histology  Other _______________________________
Section G: Soft Tissue Sarcoma
29. What is the subtype of soft tissue sarcoma?
 Angiosarcoma
 Hemangiopericytoma
 Solitary fibrous tumors
 Other _______________________
Section H: Non-Small Cell Lung Cancer (NSCLC)
30. Is the disease unresectable, locally advanced, recurrent, or metastatic?  Yes  No
31. What is the ECOG performance status of the member? __________
32. Does the disease express non-squamous cell histology?  Yes  No
33. Is there a history of recent hemoptysis?  Yes  No
34. What is the intent of treatment?
 1st line therapy, no further questions
 Continuation maintenance therapy, skip to #38
 Subsequent therapy, skip to #36
 Other _______________________________
Send completed form to: CVS Caremark Specialty Programs. Fax: 1-866-237-5512
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. Avastin HMSA 5/2017.
CVS Caremark Specialty Programs ● 2969 Mapunapuna Place ● Honolulu, HI 96819
Phone: 1-808-254-4414 ● Fax: 1-866-237-5512 ● www.caremark.com
Page 3 of 5
35. Is the tumor known to be positive for any of the following? No further questions.
 Yes  No  Not applicable/unknown
 EGFR sensitizing mutation
 ALK rearrangement
 ROS1 rearrangement
 PD-L1 expression (≥50%)
36. Is the tumor known to be positive for any of the following? If yes, please indicate.
 EGFR sensitizing mutation
 ALK rearrangement
 ROS1 rearrangement
 PD-L1 expression (≥50%)
 None of the above
 Other _______________________________
37. Which therapy has the member experienced disease progression on? Action Required: Please attach
documentation from the medical record showing previous therapy. No further questions.
 Erlotinib (Tarceva)


 Afatinib (Gilotrif)
 Crizotinib (Xalkori) 

 Gefitinib (Iressa)
 Osimertinib (Tagrisso) 

 Ceritinib (Zykadia)
 Alectinib (Alecensa)  

 Pembrolizumab (Keytruda)
 None of the above
38. Has the member achieved tumor response following first-line chemotherapy? Action Required: Please attach
documentation with previous treatment history. If Yes, skip to #40  Yes  No
39. Is the disease stable following first-line chemotherapy? Action Required: Please attach documentation with
previous treatment history.  Yes  No
40. Was Avastin previously used with a first-line pemetrexed/platinum chemotherapy regimen? Action Required: If
Yes, please attach documentation with previous treatment history.  Yes  No
Section I: Colorectal Cancer
41. In what clinical setting is Avastin used?
 Neoadjuvant therapy for T4b colorectal cancer prior to colectomy, no further questions
 Therapy for rectal cancer stage II or III (T3, N0, M0; any T, N1-2, M0; or T4) and/or locally unresectable or
medically inoperable, no further questions
 Neoadjuvant/perioperative therapy for resectable metastases
 Adjuvant therapy for resectable metastases, skip to #43
 Therapy for unresectable advanced or metastatic disease, skip to #44
 Other____________________________
42. Does the member have resectable synchronous liver and/or lung metastases only?
 Yes, no further questions  No
43. Has the member been previously treated with chemotherapy? Action Required: Please attach documentation with
previous treatment history.  Yes  No No further questions.
44. Did the member receive adjuvant FOLFOX or CapeOX within past 12 months? Action Required: Please attach
documentation with previous treatment history.  Yes, no further questions  No
45. What is the line of therapy?
 Initial therapy
 Therapy after 1st progression, skip to #50
 Other _____________________________
46. Is the member an appropriate candidate for intensive therapy?  Yes, no further questions  No
Send completed form to: CVS Caremark Specialty Programs. Fax: 1-866-237-5512
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. Avastin HMSA 5/2017.
CVS Caremark Specialty Programs ● 2969 Mapunapuna Place ● Honolulu, HI 96819
Phone: 1-808-254-4414 ● Fax: 1-866-237-5512 ● www.caremark.com
Page 4 of 5
47. Does the member have unresectable advanced or metastatic disease?
 Yes  No If New Start, no further questions.
48. What is the line of therapy?
 Therapy after 1st progression/second-line therapy
 Other _____________________________
49. Did the cancer progress on a first-line Avastin-containing regimen?  Yes  No
50. Did the member receive initial treatment with an oxaliplatin-based regimen (FOLFOX or CapeOX)? Action
Required: Please attach documentation with previous treatment history.  Yes, no further questions  No
51. Did the member receive initial treatment with an irinotecan-based regimen (FOLFIRI)? Action Required: Please
attach documentation with previous treatment history.  Yes, no further questions  No
52. Did the member receive initial treatment with a 5-FU/leucovorin- or Xeloda (capecitabine)-based regimen? Action
Required: Please attach documentation with previous treatment history.  Yes  No
Section J: Malignant Pleural Mesothelioma:
53. Is Avastin being prescribed for any of the following?
 Treatment of unresectable or medically inoperable clinical stage I to III disease with epithelial or mixed
histology?
 Treatment of clinical stage IV disease or a tumor with sarcomatoid histology
 None of the above
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)
Send completed form to: CVS Caremark Specialty Programs. Fax: 1-866-237-5512
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. Avastin HMSA 5/2017.
CVS Caremark Specialty Programs ● 2969 Mapunapuna Place ● Honolulu, HI 96819
Phone: 1-808-254-4414 ● Fax: 1-866-237-5512 ● www.caremark.com
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