Download Cyramza - BCBSGA

REVIEW REQUEST FOR
Ramucirumab (Cyramza®)
Provider Data Collection Tool Based on Medical Policy DRUG.00067
Complete this form in its entirety and fax to UM Call Center 404-848-2448
Policy Last Review Date:
Request Date:
Initial Request
Buy and bill
05/05/2016
/
Policy Effective Date: 06/28/2016
Provider Tool Effective Date: 06/28/2016
/
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)
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:
Ramucirumab (Cyramza®)
J3908
(mg/kg)
Other:
(Other)
When did the individual first start this drug?
/
/
Duration:
(Weeks)
Frequency (Days, Wks, Months)
Start Date For This Request:
/
/
This Medical Policy based provider data collection tool is intended to facilitate a UM medical necessity review request for use
of ramucirumab (Cyramza®) in the treatment of the following medical conditions: Esophageal, Gastric, and Gastroesophageal
Junction Adenocarcinoma; Non-Small Cell Lung Cancer (NSCLC); and Colorectal Cancer.
Under the appropriate disease section below, please check all that apply to the individual.
REVIEW REQUEST FOR
Ramucirumab (Cyramza®)
Provider Data Collection Tool Based on Medical Policy DRUG.00067
Policy Last Review Date:
05/05/2016
Policy Effective Date: 06/28/2016
Provider Tool Effective Date: 06/28/2016
Esophageal, Gastric, and Gastroesophageal Junction Adenocarcinoma
The request is for use of Ramucirumab (Cyramza®) in the treatment of an individual diagnosed with:
(Identify the diagnosis that applies to the individual)
Advanced (non-resectable) or metastatic esophageal adenocarcinoma
Advanced (non-resectable) or metastatic gastric adenocarcinoma
Advanced (non-resectable) or metastatic gastroesophageal junction adenocarcinoma
If any of the above are checked please answer the following:
Cyramza®) will be given as a single agent
Cyramza®) will be given in combination with paclitaxel
Non-Small Cell Lung Cancer (NSCLC)
The request is for use of Ramucirumab (Cyramza®) in the treatment of an individual diagnosed with
metastatic non-small cell lung cancer NSCLC
(If checked answer the following when the item applies to the individual)
Cyramza® will be given in combination with docetaxel
Individual DOES NOT have an epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK)
genomic tumor aberration
Individual has experienced disease progression while on or after platinum-containing chemotherapy
Individual has an epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK)
genomic tumor mutation. (If checked complete the following that apply to the individual)
Individual has experienced disease progression while on a U.S. Food & Drug Administration (FDA)-approved
Therapy (for example, afatinib, crizotinib, erlotinib, or gefitinib) for these mutations prior to
receiving Cyramza®
Individual has experienced disease progression while on or after platinum-containing chemotherapy
Colorectal Cancer
The request is for use of Ramucirumab (Cyramza®)) in the treatment of an individual diagnosed with
metastatic colorectal cancer (mCRC).
(If checked answer the following when the item applies to the individual)
Cyramza®) will be given in combination with irinotecan, folinic acid, and 5-fluorouracil (FOLFIRI)
The individual has experienced disease progression during or after bevacizumab-containing chemotherapy
The individual has experienced disease progression during or after oxaliplatin-containing chemotherapy
The individual has experienced disease progression during or after fluoropyrimidine-containing chemotherapy
Other Indications not listed above (Please submit all supporting documents including labs, progress notes, imaging, etc.,
for review.)
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REVIEW REQUEST FOR
Ramucirumab (Cyramza®)
Provider Data Collection Tool Based on Medical Policy DRUG.00067
Policy Last Review Date:
05/05/2016
Policy Effective Date: 06/28/2016
Provider Tool Effective Date: 06/28/2016
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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