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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: / Initial Request Buy and bill Policy Effective Date: 01/14/2014 Provider Tool Effective Date: 01/14/2014 / Subsequent Request Individual’s Name: Date of Birth: / / 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) / / Duration: Start Date For This Request: (Weeks) / / (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. / / 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. .