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REVIEW REQUEST FOR
Abraxane ™ - Oncology
Complete form in its entirety and fax to: Anthem Blue Cross 866-408-7195
Provider Data Collection Tool Based on Clinical Guideline-DRUG-01
Policy Last Review Date: 02/13/2014
Toolkit: 05/02/2014
Request Date:
Initial Request
Buy and bill
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Policy Effective Date: 04/15/2014
Provider Tool Effective Date: 05/07/2014
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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)
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:
Abraxane™ J9264
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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(mg/m2)
(other)
Please check all that apply to the individual:
Complete this section before proceeding to the following disease specific sections:
Please check if the individual has been treated with any chemotherapy medications in the past (If checked, provide the chemotherapy
medications that the individual has received):
(1)
Breast Cancer (Please check all that apply):
Individual has breast cancer
Will be given after failure of combination chemotherapy for metastatic disease
Prior therapy included anthracycline
Prior therapy DID NOT include anthracycline as it was clinically contraindicated
Other:
Will be given for disease relapse within 6 months of adjuvant chemotherapy
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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.
Prior therapy included anthracycline
Prior therapy DID NOT include anthracycline as it was clinically contraindicated
Other:
Will be given as single agent for recurrent or metastatic disease (Please check all that apply):
Human epidermal growth factor receptor-2 (HER-2)-negative
Hormone receptor-negative
Hormone receptor-positive
With visceral crisis
Endrocrine therapy refractory
Progressive disease with no clinical benefit after three consecutive endocrine therapy regimens or symptomatic visceral disease
Other:
(2) Non-Small Cell Lung Cancer (NSCLC)
Individual has locally advanced or metastatic non-small cell lung cancer (Please check all that apply):
Individual is not a candidate for curative surgery or radiation therapy
Given as first-line therapy
Will be given in combination with carboplatin
Other:
Individual has experienced hypersensitivity reactions after receiving paclitaxel or docetaxel despite premedication
Standard hypersensitivity medications are contraindicated
Other:
(3) Ovarian Cancer (Epithelial Ovarian Cancer/Fallopian Tube Cancer/Primary Peritoneal Cancer) (NOTE: does not apply for immediate
treatment of biochemical relapse)
Will be given for epithelial ovarian cancer
Will be given for fallopian tube cancer
Will be given for primary peritoneal cancer
Will be given as single agent
For persistent disease or recurrence
Other:
Other:
(4) Pancreatic Adenocarcinoma (excludes immediate treatment of biochemical relapse)
Individual has pancreatic adenocarcinoma:
Locally advanced unresectable
Metastatic
Individual has a good performance status
Will be given in combination with gemcitabine
Will be given as first-line treatment
Other:
(5) Melanoma
Individual has melanoma
Will be given as single agent
Individual has unresectable stage III in-transit metastases
Individual has local/satellite and/or in-transit unresectable recurrence
Individual has incompletely resected or unresectable nodal recurrence
Individual has recurrent or metastatic disease with good performance status (ECOG Performance Status 0-2)
Other:
(6) Other Use(s) (Please 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
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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.
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.