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REVIEW REQUEST FOR Firmagon®, Zoladex®, Vantas®, Supprelin® LA, Lupron®, Eligard®, Trelstar® (Gonadotropin Releasing Hormone Analogs) Provider Data Collection Tool Based on Clinical Guideline DRUG-15 Complete form in its entirety and fax to: CT: 203-985-6460 ME & NH: 603-695-7014 Policy Last Review Date: 05/10/2012 Request Date: Initial Request Buy and bill / Policy Effective Date: 07/10/2012 Provider Tool Effective Date: 07/10/2012 / Subsequent Request Individual’s Name: Date of Birth: / / Individual’s Phone Number: Insurance Identification Number: Primary Diagnosis: ICD-9 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/HCPS Code (if known) Dose to be administered: Vantas® ® Supprelin LA Lupron® ® Eligard Trelstar® ® Zoladex Firmagon® J1675 J1675 J1950 J9217 J3315 J9202 J9155 J9225 J9226 J9217 J9218 (mg) J9218 Other: When did the individual first start this drug? / / Duration: (Weeks) Please check all that apply to the individual: Breast Cancer Individual with hormone receptor positive breast cancer Individual is pre-menopausal Individual is peri-menopausal Other (Other) Frequency (Days, Wks, Months) Start Date For This Request: / / Ovarian Cancer Individual with ovarian cancer (including fallopian tube cancer and primary peritoneal cancer) Hormonal therapy for clinical relapse in individual with stage II-IV granulosa cell tumors Hormonal therapy for treatment of epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer as a single agent Progressive, stable or persistent disease on primary chemotherapy Relapse after complete remission following primary chemotherapy Stage II-IV disease showing partial response to primary treatment Low grade or focal recurrences after a disease free interval of greater than 6 months Other Prostate Cancer Individual with prostate cancer Clinically localized disease with intermediate (T2b to T2c cancer, Gleason score of 7, or PSA value of 10-20ng/mL) or higher risk of recurrence Locally advanced disease Other advanced, recurrent, or metastatic disease In combination with antiandrogen (flutamide or bicalutamide) for locally confined stage T2b-T4 (stage B2-C) disease To be used to shrink an enlarged prostate to an acceptable size prior to brachytherapy, cryosurgery or external beam radiation therapy Other Central Precocious Puberty Treatment of child known to have central precocious puberty (defined as beginning of secondary sexual characteristics before age 8 in girls and 9 in boys) Other Gynecology Uses Individual with chronic pelvic pain Noncyclical pain lasting 6 or more months Pain localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks Pain is of sufficient severity to cause functional disability or lead to medical care Request for continuation of treatment beyond 3 months Individual has received symptomatic relief from prior treatment Other Individual with endometriosis To induce amenorrhea in women in certain populations Menstruating woman with severe thrombocytopenia Menstruating woman with aplastic anemia Other Individual with dysfunctional uterine bleeding Request for endometrial thinning prior to endometrial ablation for dysfunctional uterine bleeding Preoperative treatment as adjunct to surgical treatment of uterine fibroids (leiomyoma uteri) Will be used to reduce size of fibroids to allow for a vaginal procedure Other Prior to surgical treatment (myomectomy or hysterectomy) in individual with documented anemia Other Other Use(s) (Please submit all supporting documents including labs, progress notes, imaging, etc., for review.) Page 2 of 3 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. Page 3 of 3