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REVIEW REQUEST FOR
Provenge®
Complete form in its entirety and fax to Anthem UM Services (303) 831 6428 or (800) 763-3142
Colorado referral line (800) 832-7850 Nevada referral line (800) 336-7767
Provider Data Collection Tool Based on Medical Policy MED.00106
Policy Last Review Date: 05/09/2013
Policy Effective Date: 07/09/2013
Provider Tool Effective Date: 09/03/2013
Request Date:
/
/
Initial Request
Subsequent Request
Buy and bill
Medication(s) is to be dispensed, delivered, and managed by :
Caremark, or
Coram
Ship Medication to:
MD Office
Individual’s Home
Other: (please specify):
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:
Provenge®
Q2043 Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
/
/
Duration:
Start Date For This Request:
(Weeks)
/
/
(units)
(other)
Page 1 of 2
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. Independent licensee of the
Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and
Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Utilization management administered
by either Anthem UM Services, Inc. or American Imaging Management each separate companies.
Please check all that apply to the individual:
Request is for autologous cellular immunotherapy for the treatment of prostate cancer in an individual with
metastatic castrate resistant prostate cancer (CRPC) or hormone refractory prostate cancer (HRPC) (Please check
all that aply):
Individual is asymptomatic or minimally symptomatic
ECOG (Eastern Cooperative Oncology Group) performance status 0-1
No visceral metastasis, pathologic long bone fracture, or spinal cord compression
Life expectancy of greater than 6 months
Serum prostate-specific antigen (PSA) level of 5 ng/ml or more
Serum testosterone level less than 50 ng/dl (17 nmol/l)
Progressive disease based on imaging studies or PSA measurements
No treatment within the previous 28 days with systemic glucocorticoids, external-beam radiation
(EBRT), surgery, or systemic therapy for prostate cancer (except medical or surgical castration)
No chemotherapy within the previous 3 months
Other
Other
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 2 of 2
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. Independent licensee of the
Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and
Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Utilization management administered
by either Anthem UM Services, Inc. or American Imaging Management each separate companies.