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REVIEW REQUEST FOR Ramucirumab (Cyramza®) Provider Data Collection Tool Based on Medical Policy DRUG.00067 Policy Last Review Date: Request Date: Initial Request Buy and bill 05/05/2016 / Policy Effective Date: 06/28/2016 Provider Tool Effective Date: 06/28/2016 / 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: Ramucirumab (Cyramza®) J3908 (mg/kg) Other: (Other) When did the individual first start this drug? / / Duration: (Weeks) Frequency (Days, Wks, Months) Start Date For This Request: / / This Medical Policy based provider data collection tool is intended to facilitate a UM medical necessity review request for use of ramucirumab (Cyramza®) in the treatment of the following medical conditions: Esophageal, Gastric, and Gastroesophageal Junction Adenocarcinoma; Non-Small Cell Lung Cancer (NSCLC); and Colorectal Cancer. Under the appropriate disease section below, please check all that apply to the individual. REVIEW REQUEST FOR Ramucirumab (Cyramza®) Provider Data Collection Tool Based on Medical Policy DRUG.00067 Policy Last Review Date: 05/05/2016 Policy Effective Date: 06/28/2016 Provider Tool Effective Date: 06/28/2016 Esophageal, Gastric, and Gastroesophageal Junction Adenocarcinoma The request is for use of Ramucirumab (Cyramza®) in the treatment of an individual diagnosed with: (Identify the diagnosis that applies to the individual) Advanced (non-resectable) or metastatic esophageal adenocarcinoma Advanced (non-resectable) or metastatic gastric adenocarcinoma Advanced (non-resectable) or metastatic gastroesophageal junction adenocarcinoma If any of the above are checked please answer the following: Cyramza®) will be given as a single agent Cyramza®) will be given in combination with paclitaxel Non-Small Cell Lung Cancer (NSCLC) The request is for use of Ramucirumab (Cyramza®) in the treatment of an individual diagnosed with metastatic non-small cell lung cancer NSCLC (If checked answer the following when the item applies to the individual) Cyramza® will be given in combination with docetaxel Individual DOES NOT have an epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberration Individual has experienced disease progression while on or after platinum-containing chemotherapy Individual has an epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor mutation. (If checked complete the following that apply to the individual) Individual has experienced disease progression while on a U.S. Food & Drug Administration (FDA)-approved Therapy (for example, afatinib, crizotinib, erlotinib, or gefitinib) for these mutations prior to receiving Cyramza® Individual has experienced disease progression while on or after platinum-containing chemotherapy Colorectal Cancer The request is for use of Ramucirumab (Cyramza®)) in the treatment of an individual diagnosed with metastatic colorectal cancer (mCRC). (If checked answer the following when the item applies to the individual) Cyramza®) will be given in combination with irinotecan, folinic acid, and 5-fluorouracil (FOLFIRI) The individual has experienced disease progression during or after bevacizumab-containing chemotherapy The individual has experienced disease progression during or after oxaliplatin-containing chemotherapy The individual has experienced disease progression during or after fluoropyrimidine-containing chemotherapy Other Indications not listed above (Please submit all supporting documents including labs, progress notes, imaging, etc., for review.) Page 2 of 3 REVIEW REQUEST FOR Ramucirumab (Cyramza®) Provider Data Collection Tool Based on Medical Policy DRUG.00067 Policy Last Review Date: 05/05/2016 Policy Effective Date: 06/28/2016 Provider Tool Effective Date: 06/28/2016 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 designees 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 Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan. Page 3 of 3