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REVIEW REQUEST FOR Plan Octreotide acetate (Sandostatin®/ Sandostatin® LAR Depot) Provider Data Collection Tool Based on Clinical Guideline DRUG-45 Policy Last Review Date: 11/03/2016 Policy Effective Date: Request Date: / / Initial Authorization Request Buy and bill 12/28/2016 Provider Tool Effective Date: Subsequent Request Individual’s Name: Date of Birth: / / Individual’s Phone Number: Insurance Identification Number: Primary Diagnosis: 12/28/2016 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: Sandostatin® J2353 J2354 Other: When did the individual first start this drug? Frequency (Days, Wks, Months) / / Duration: Start Date For This Request: (Weeks) / / (mg) (mcg) (Other) This clinical guideline based data collection tool is for a medical necessity review request for clinical use of octreotide acetate (Sandostatin®, and Sandostatin® LAR Depot) in the treatment of acromegaly, carcinoid tumors, vasoactive intestinal peptide tumors, and off-label treatment for other conditions. Please check all of the following that apply to the individual. REVIEW REQUEST FOR Octreotide acetate (Sandostatin®/ Sandostatin® LAR Depot) Plan Provider Data Collection Tool Based on Clinical Guideline DRUG-45 Policy Last Review Date: 11/03/2016 Policy Effective Date: 12/28/2016 Provider Tool Effective Date: 12/28/2016 I. Acromegaly Request is for octreotide acetate (Sandostatin®) for the treatment of an individual with acromegaly (If checked, answer the following when it applies) Individual has had an inadequate response to or cannot be treated with surgical resection, pituitary irradiation, and bromocriptine mesylate at maximally tolerated doses. II. Carcinoid Tumors (Well-differentiated Neuroendocrine Tumors) Request is for octreotide acetate (Sandostatin®) for the treatment of an individual with carcinoid tumors (If checked, identify the appropriate treatment indication(s) below) Metastatic carcinoid tumors Carcinoid syndrome to suppress or inhibit severe diarrhea and flushing episodes associated with the disease Prophylactic administration prior to biopsy in an individual with a suspected functioning carcinoid tumor Prophylactic administration prior to induction of anesthesia in an individual with a functional carcinoid tumor Prophylactic administration preoperatively to a surgical procedure in an individual with a functional carcinoid tumor. Request is for supplemental use of short-acting Sandostatin® for rapid relief of symptoms or for breakthrough symptoms in an individual with carcinoid tumors while taking longacting octreotide acetate (Sandostatin® LAR Depot) III. Other Neuroendocrine Tumors Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an individual with neuroendocrine tumors. Request is for supplemental use of short-acting Sandostatin® for rapid relief of symptoms or for breakthrough symptoms in an individual with carcinoid tumors while taking long-acting octreotide acetate (Sandostatin® LAR Depot) (If EITHER of the above is checked, identify the appropriate treatment indication(s) below) Management of unresectable locoregional disease or distant metastasis As treatment of the profuse watery diarrhea associated with VIPomas Treatment of underlying Zollinger-Ellison syndrome Prophylactic treatment prior to surgery for gastrinoma REVIEW REQUEST FOR Octreotide acetate (Sandostatin®/ Sandostatin® LAR Depot) Plan Provider Data Collection Tool Based on Clinical Guideline DRUG-45 Policy Last Review Date: 11/03/2016 IV. Policy Effective Date: 12/28/2016 Provider Tool Effective Date: 12/28/2016 Other Indications Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an individual with bleeding gastroesophageal (GE) varices (If checked, mark the following that apply) Gastroesophageal varices are associated with liver disease Octreotide acetate will be used in combination with endoscopic therapy (that is, band ligation or sclerotherapy) or alone if endoscopic therapy is not immediately available Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an individual with central nervous system (CNS) meningiomas that are surgically inaccessible, recurrent, or progressive and the individual is not a candidate for further radiation therapy Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an individual with chemotherapy- or radiation-induced diarrhea that is unresponsive to conventional antidiarrheal medications (for example, diphenoxylate and atropine or loperamide) Request is for Sandostatin® or Sandostatin® LAR Depot for the treatment of an individual with malignant bowel obstruction, to manage gastrointestinal (GI) symptoms (such as nausea, pain, or vomiting). Request is for supplemental use of short-acting Sandostatin® for rapid relief of symptoms or for breakthrough symptoms in an individual with an OTHER INDICATION while taking long-acting octreotide acetate (Sandostatin® LAR Depot) Please specify the INDICATION: _____________________________ Request is for Sandostatin® or Sandostatin® LAR Depot for treatment of a condition not specified above. (If checked, please check the applicable condition below and submit all documentation to support the request) Chylothorax in neonates Diarrhea (severe, secretory) associated with acquired immunodeficiency syndrome (AIDS) Gastrointestinal (GI) tract conditions (If checked, mark the applicable condition below) gastroparesis pancreatitis prevention of postoperative complications (for example, fistulae) following pancreatic surgery short bowel syndrome upper GI bleeding (such as, non-variceal hemorrhage) vascular (arteriovenous) malformations Graves' ophthalmopathy Hypothalamic obesity (control of hyperinsulinemia) Other carcinomas (such as, advanced breast cancer, hepatocellular cancer, or prostate cancer) Polycystic kidney disease Other: _______________________________________________ REVIEW REQUEST FOR Plan Octreotide acetate (Sandostatin®/ Sandostatin® LAR Depot) Provider Data Collection Tool Based on Clinical Guideline DRUG-45 Policy Last Review Date: 11/03/2016 Policy Effective Date: 12/28/2016 Provider Tool Effective Date: 12/28/2016 This request is being submitted: Pre-Claim Post–Claim. If checked, please attach the claim or indicate the claim number I confirm that the information entered on this form is accurate and complete based on the records available at the time of this request. I understand the health plan or its designees may request medical documentation to verify the accuracy of the information reported on this form. Name and Title of Provider or Provider Representative Completing Form and 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.