Download review request for

REVIEW REQUEST FOR
Prolia® Xgeva® - Bone Resorption Inhibitor
Complete form in its entirety and fax to: Anthem Blue Cross 866-408-7195
Provider Data Collection Tool Based on Medical Policy DRUG.00055
Policy Last Review Date: 11/14/2013
Request Date:
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Initial Request
Buy and bill
Policy Effective Date: 01/14/2014
Provider Tool Effective Date: 01/14/2014
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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:
Diagnosis 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/HCPCS Code (if known)
Dose to be administered:
Prolia®
J0897
Xgeva®
J0897
Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
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/
Duration:
Start Date For This Request:
(Weeks)
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/
(mg)
Other
Please check all that apply to the individual:
Prolia®:
1.
Osteoporosis
For the treatment of osteoporosis (defined as a T score -2.5 or less)
In a postmenopausal adult (greater than or equal to 18 years of age) woman
In an adult (greater than or equal to 18 years of age) man
Please check all that apply:
Individual has had at least one osteoporotic (minimal trauma) fracture
Individual has two or more of the following risk factors for osteoporotic fracture:
hypogonadism or premature ovarian failure
low body mass
smoking
rheumatoid arthritis
alcohol intake of 3 or more drinks/day
vitamin D deficiency
low calcium intake
Page 1 of 3
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance
Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies,
Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
hyperkyphosis
parental hip fracture
multiple falls
medication: anticoagulants, anticonvulsants, cancer chemotherapeutic drugs, gonadatropin-releasing
hormone agonists, (glucocorticoid daily dosage equivalent to 5mg or greater of prednisone for at least 3 months)
Individual has failed or is intolerant to other available osteoporosis therapies (e.g. bisphosphonates).
Other
2.
Breast Cancer
For the treatment of bone loss in an adult (greater than or equal to 18 years of age) woman receiving adjuvant aromatase inhibitor therapy
for breast cancer
Please check all that apply:
Individual has had at least one osteoporotic (minimal trauma) fracture
Individual has one or more of the following risk factors for osteoporotic fracture:
hypogonadism or premature ovarian failure
low body mass
smoking
rheumatoid arthritis
alcohol intake of 3 or more drinks/day
vitamin D deficiency
low calcium intake
hyperkyphosis
parental hip fracture
multiple falls
medication: anticoagulants, anticonvulsants, cancer chemotherapeutic drugs, gonadatropin-releasing hormone agonists,
(glucocorticoid daily dosage equivalent to 5mg or greater of prednisone for at least 3 months)
Other
2.
Prostate Cancer
For the treatment of bone loss in an adult (greater than or equal to 18 years of age) man receiving androgen deprivation therapy for nonmetastatic prostate cancer
Please check all that apply:
Individual has had at least one osteoporotic (minimal trauma) fracture
Individual has one or more of the following risk factors for osteoporotic fracture:
hypogonadism or premature ovarian failure
low body mass
smoking
rheumatoid arthritis
alcohol intake of 3 or more drinks/day
vitamin D deficiency
low calcium intake
hyperkyphosis
parental hip fracture
multiple falls
medication: anticoagulants, anticonvulsants, cancer chemotherapeutic drugs, gonadatropin-releasing hormone agonists,
(glucocorticoid daily dosage equivalent to 5mg or greater of prednisone for at least 3 months)
Other
Xgeva®:
1.
Bone Metastases
Will be used for prevention of skeletal-related events in an adult (greater than or equal to 18 years of age) with bone metastases from
(Please check all that apply):
multiple myeloma
castration-recurrent prostate cancer
other solid tumors
Other
2. Giant Cell Tumor of the Bone
For the treatment of localized or metastatic giant cell tumor of the bone (GCTB)
Tumor is unresectable
Surgical resection is likely to result in severe morbidity
Individual is an adult (greater than or equal to 18 years of age)
Individual is a skeletally mature adolescent (defined by at least 1 mature long bone [for example: closed epiphyseal growth plate
of the humerus])
Other
Page 2 of 3
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance
Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies,
Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
.
Other Use(s) (Please submit all supporting documents including labs, progress notes, imaging, etc., for review.)
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
designee 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
Page 3 of 3
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance
Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies,
Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
.