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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.