Download review request for

REVIEW REQUEST FOR
Provenge® (Sipuleucel-T)
Complete form in its entirety and fax to: Anthem Blue Cross 866-408-7195
Provider Data Collection Tool Based on Medical Policy MED.00106
Policy Last Review Date: 05/15/2014
Request Date:
Initial Request
Buy and bill
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Policy Effective Date: 07/15/2014
Provider Tool Effective Date: 07/15/2014
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Subsequent Request
Individual’s Name:
Date of Birth:
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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)
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Duration:
Start Date For This Request:
(Weeks)
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(units)
(other)
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 apply):
Individual is asymptomatic or minimally symptomatic
ECOG (Eastern Cooperative Oncology Group) performance status 0-1
No visceral metastasis
No pathologic long bone fracture,
No pathologic long bone fracture or spinal cord compression within the last 3 months
Life expectancy of greater than 6 months
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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.
Serum testosterone level less than 50 ng/dl (17 nmol/l)
Progressive disease based on (check all that apply):
Serum prostate-specific antigen (PSA) level of greater than or equal to 5 ng/ml
Evidence of progressively increasing PSA values
Osseous metastases on imaging with objective evidence of progression regardless
of PSA levels
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.
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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
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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.