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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 Page 1 of 5 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 Page 5 of 5