Download Perjeta - BCBSGA

REVIEW REQUEST FOR
Pertuzumab (Perjeta®)
Provider Data Collection Tool Based on Medical Policy DRUG-52
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:
Request Date:
/
/
Initial Authorization Request
Buy and bill
06/28/2016
Provider Tool Effective Date:
02/11/2016
Subsequent Request
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)
Individual’s Height
(in) (cm)
Provider ID Number:
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering Provider):
Provider ID Number:
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:
pertuzumab (Perjeta®)
J9306
Other:
When did the individual first start this drug?
/
/
Duration:
(Weeks)
(mg/)
(Other)
Frequency (Days, Wks, Months)
Start Date For This Request:
/
/
Please check all that apply to the individual:
Individual is diagnosed with HER2-positive (HER2+) breast tumor
(If checked, mark the following as appropriate to the individual) Diagnosis is documented by:
Immunohistochemistry (IHC) is 3+;
In situ hybridization (ISH) positive by Single probe average HER2 copy number greater than
or equal to 6.0 signals/cell;
In situ hybridization (ISH) positive by Dual-probe HER2/CEP 17 ratio greater than or
equal to 2.0;
In situ hybridization (ISH) positive by Dual-probe HER2/CEP17 ratio less than 2.0
with an average HER2 copy number greater than or equal to 6.0 signals/cell
REVIEW REQUEST FOR
Pertuzumab (Perjeta®)
Provider Data Collection Tool Based on Medical Policy DRUG-52
Policy Last Review Date:
05/05/2016
Policy Effective Date: 06/28/2016
Provider Tool Effective Date:
02/11/2016
The individual has metastatic breast cancer (If checked, please answer the following
as appropriate for the individual)
Pertuzumab will be used in combination with trastuzumab and docetaxel*
Pertuzumab will be used in combination with trastuzumab and paclitaxel* ;
The combination chemotherapy with pertuzumab will be used as single-line anti-HER2
chemotherapy for metastatic disease until progression.
*Note: If docetaxel or paclitaxel treatment is contraindicated upon initiation or discontinued
(for example, related to toxicity), treatment with pertuzumab and trastuzumab may continue.
The individual has operable early stage, locally advanced, or inflammatory breast cancer and will
undergo neoadjuvant (prior to surgery) therapy
(If checked, mark all of the following that apply to the individual)
Primary tumor is larger than 2 cm in diameter or individual is node positive
(clinically evident by palpation or imaging)
ECOG performance status 0-2
Pertuzumab will be used in combination with trastuzumab and docetaxel with or without
carboplatin
Pertuzumab will be used in combination with trastuzumab and paclitaxel
Pertuzumab will be used in combination with trastuzumab and another drug.
Specify the drug:_______________________________
Complete surgical resection is planned if neoadjuvant therapy results in a sufficient
therapeutic response
Not continued post-operatively (adjuvant)
Individual has early stage or locally advanced breast cancer and will undergo adjuvant systemic
therapy (If checked, mark all of the following that apply to the individual)
Pertuzumab will be used for a maximum of 6 cycles
Pertuzumab was NOT used as neoadjuvant therapy
Primary tumor measures 2 cm or more in diameter or is lymph node positive
Pertuzumab will be used in combination with 12 month (52 weeks) course of
trastuzumab AND docetaxel with or without carboplatin
Pertuzumab will be used in combination with 12 month (52 weeks) course of
trastuzumab AND paclitaxel
Pertuzumab will be used in combination with 12 month (52 weeks) course of
trastuzumab AND another drug
Specify the drug:________________________
2. Other Use(s) not listed above. (Please submit all supporting documents including labs, progress
notes, imaging, etc., for review.)
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REVIEW REQUEST FOR
Pertuzumab (Perjeta®)
Provider Data Collection Tool Based on Medical Policy DRUG-52
Policy Last Review Date:
05/05/2016
Policy Effective Date: 06/28/2016
Provider Tool Effective Date:
02/11/2016
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
Date
& attestation (Please Print)*
*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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