Download Abraxane

REVIEW REQUEST FOR
Paclitaxel, protein-bound (Abraxane®)
Provider Data Collection Tool Based on Clinical Guideline DRUG-50
Complete this form in its entirety and fax to UM Call Center 404-848-2448
Policy Last Review Date:
05/05/2016
Request Date:
/
Initial Request
Buy and bill
/
Policy Effective Date:
06/28/2016
Provider Tool Effective Date:
Subsequent Request
Individual’s Name:
Date of Birth:
/
/
Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
06/28/2016
Diagnosis Code(s) (if known):
Ordering Provider Name & Specialty:
Individual’s Weight
(lbs) (kg)
Individual’s Height
(in) (cm)
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:
(mg/m2)
Paclitaxel, protein-bound (Abraxane®)
J9264
(Other)
Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
/
/
Duration:
Start Date For This Request:
(Weeks)
/
/
This clinical guideline base data collection tool is for a medical necessity review request for use of protein-bound
paclitaxel (Abraxane ®) for the treatment of relapsed or metastatic breast cancer, locally advanced or metastatic nonsmall cell lung cancer, metastatic adenocarcinoma of the pancreas, and other off-label oncologic conditions..
Please read carefully, select the appropriate medical condition and check all that applies to the individual:
Breast Cancer
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Request is for use of Abraxane as a single agent in the treatment of relapsed or metastatic breast cancer
Request is for use of Abraxane as a single line of therapy in the treatment of relapsed or metastatic breast cancer
Request is for use of solvent-based Abraxane in the treatment of any breast cancer when allergic reaction is
documented
REVIEW REQUEST FOR
Paclitaxel, protein-bound (Abraxane®)
Provider Data Collection Tool Based on Clinical Guideline DRUG-50
Policy Last Review Date:
05/05/2016
Policy Effective Date:
06/28/2016
Provider Tool Effective Date:
06/28/2016
Malignant Melanoma
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□
Request is for use of Abraxane as a single agent in the treatment of relapsed or refractory melanoma
Individual has an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2
following at least 1 prior therapy.
Non-Small Cell Lung Cancer (NSCLC)
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Request is for use of Abraxane as first-line therapy in the treatment of locally advanced or metastatic NSCLC
Abraxane will be given in combination with carboplatin or cisplatin.
Ovarian Cancer (Epithelial Ovarian Cancer, Fallopian Tube Cancer, or Primary Peritoneal Cancer)
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Request is for use of Abraxane as a single agent in the treatment of ovarian cancer (epithelial ovarian cancer,
fallopian tube cancer, or primary peritoneal cancer)
Individual’s disease is persistent or recurrent.
Pancreatic Cancer
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Request is for use of Abraxane as first-line or later therapy in the treatment of locally advanced or metastatic
adenocarcinoma of the pancreas
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Abraxane will be given in combination with gemcitabine as a single-line of therapy
Other Use(s) (Please list the use; and 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
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
& attestation (Please Print)*
/
Date
*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.
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REVIEW REQUEST FOR
Paclitaxel, protein-bound (Abraxane®)
Provider Data Collection Tool Based on Clinical Guideline DRUG-50
Complete this form in its entirety and fax to UM Call Center 404-848-2448
Policy Last Review Date:
05/05/2016
Policy Effective Date:
06/28/2016
Provider Tool Effective Date:
06/28/2016