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REVIEW REQUEST FOR Bevacizumab (Avastin®) For Non-Ophthalmologic Indications Provider Data Collection Tool Based on Medical Policy DRUG.00038 Complete this form in its entirety and fax to UM Call Center 404-848-2448 Policy Last Review Date: 11/05/2015 Request Date: / Initial Request Buy and bill / Policy Effective Date 01/05/2016 Provider Tool Effective Date Subsequent Request Individual’s Name: Date of Birth: / / Individual’s Phone Number: Insurance Identification Number: Primary Diagnosis: 01/05/2016 Diagnosis Code(s) (if known): Ordering Provider Name & Specialty: Individual’s Weight (lbs) (kg) Provider ID Number (if known) : Office Address: Contact Person and Office Phone Number: Office Fax Number: Servicing Provider Name & Specialty (If different than Ordering Provider): Provider ID Number (if known): Office Address: Contact Person 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: Avastin® J9035 Other: When did the individual first start this drug? / / Duration: (Weeks) (mg/kg) (other) Frequency (Days, Wks, Months) Start Date For This Request: / / 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 REVIEW REQUEST FOR Bevacizumab (Avastin®) For Non-Ophthalmologic Indications Provider Data Collection Tool Based on Medical Policy DRUG.00038 Complete this form in its entirety and fax to UM Call Center 404-848-2448 Policy Last Review Date: 11/05/2015 Policy Effective Date 01/05/2016 Provider Tool Effective Date 01/05/2016 (1) Metastatic Breast Cancer Individual has been diagnosed with metastatic breast carcinoma Avastin® will be used for first line chemotherapy (Note: Hormonal therapy alone is NOT considered “chemotherapy”) Individual has been diagnosed with HER2-negative breast cancer Individual will receive Avastin® in combination with paclitaxel Individual will receive Avastin® in combination with paclitaxel protein-bound Individual will NOT be receiving other targeted biologic agents at the same time Other (2) Primary Central Nervous System Tumor Individual has been diagnosed with a primary central nervous system tumor. Individual has failed radiation therapy Avastin® is used in a single line of therapy Tumor to be treated is a World Health Organizaion (WHO) Grade III/IV glioma (If checked, please indicate the glioma type) Anaplastic astrocytoma Progressive or recurrent ependymoma Anaplastic glioma Recurrent high-grade glioma Glioblastoma Glioblastoma multiforme Other Individual will NOT be receiving other targeted biologic agents at the same time Other (3) Metastatic Cervical Cancer Individual has been diagnosed with metastatic cervical cancer Individual has recurrent or persistent disease that is not amendable to curative treatment with surgery or radiotherapy Avastin® will be used in a single line of therapy Avastin® will be used in combination with paclitaxel and topotecan chemotherapy Avastin® will be used in combination with paclitaxel and cisplatin chemotherapy Individual will NOT be receiving other targeted biologic agents at the same time Other (4) Metastatic Colon, Rectal, Colorectal, or Small Bowel Adenocarcinoma Individual has been diagnosed with metastatic colon, rectal, colorectal, or small bowel adenocarcinoma Individual will receive Avastin® in combination with 5-fluorouracil (5-FU)-based chemotherapy as first-line treatment Individual will receive Avastin® in combination with 5-FU-based chemotherapy, irinotecan, or oxaliplatin as second-line treatment Individual has progressed on a first-line Avastin® containing regimen AND will receive Avastin® in combination with 5FU-based chemotherapy, irinotecan or oxaliplatin as second-line treatment Individual will NOT be receiving other targeted biologic agents at the same 2 REVIEW REQUEST FOR Bevacizumab (Avastin®) For Non-Ophthalmologic Indications Provider Data Collection Tool Based on Medical Policy DRUG.00038 Complete this form in its entirety and fax to UM Call Center 404-848-2448 Policy Last Review Date: 11/05/2015 Policy Effective Date 01/05/2016 Provider Tool Effective Date 01/05/2016 Other (5) Non-Squamous Non-Small Cell Lung Cancer (NSCLC) Individual has been diagnosed with NSCLC. (If checked, mark all of the following that apply) Cancer is unresectable Cancer is locally advanced Cancer is recurrent Cancer is metastatic Initial Treatment for NSCLC: Avastin® will be used as first line therapy in the initial treatment of NSCLC Individual with performance status 0 -1 Individual with no history of hemoptysis Individual will receive Avastin® with platinum-based therapy (If checked indication the combination treatment) Will receive in combination with taxane Will receive in combination with pemetrexed (Alimta®) Individual will NOT be receiving other targeted biologic agents at the same time Other Maintenance Treatment for NSCLC: Avastin® to be used as maintenance therapy for NSCLC Avastin® was used as an agent in a first-line combination chemotherapy regimen Avastin® is to be used as a single agent Disease has NOT progressed since this treatment regimen started Avastin® may be used until disease progression Individual will NOT be receiving other targeted biologic agents at the same time Other (6) Metastatic Epithelial Ovarian Cancer / Fallopian Tube Cancer / Recurrent Primary Peritoneal Cancer Individual has been diagnosed with recurrent, metastatic epithelial ovarian cancer Individual has been diagnosed with fallopian tube cancer Individual has been diagnosed with recurrent, primary peritoneal cancer Avastin® will be used as a single agent or in combination with other chemotherapy Avastin® will be used in a single line of therapy Avastin® will be used for relapsed or refractory disease Individual will NOT be receiving other targeted biologic agents at the same time Other (7) Post-Radiation Necrosis Avastin® will be used to treat an individual with symptomatic post- radiation necrosis of the central nervous system Individual will NOT be receiving other targeted biologic agents at the same time 3 REVIEW REQUEST FOR Bevacizumab (Avastin®) For Non-Ophthalmologic Indications Provider Data Collection Tool Based on Medical Policy DRUG.00038 Complete this form in its entirety and fax to UM Call Center 404-848-2448 Policy Last Review Date: 11/05/2015 Policy Effective Date 01/05/2016 Provider Tool Effective Date 01/05/2016 (8) Metastatic Renal Cell Carcinoma (RCC) Individual has been diagnosed with metastatic clear cell renal carcinoma Individual will receive Avastin® in combination with interferon as first line treatment Individual has relapsed or medically unresectable stage IV disease with predominant clear cell histology Individual had progressive disease while on prior cytokine therapy Individual will receive Avastin® as single agent Other Individual will NOT be receiving other targeted biologic agents at the same time Other (9) Soft Tissue Sarcoma Avastin® will be used as a single agent to treat an individual diagnosed with angiosarcoma Avastin® will be used in combination with temozolomide for the treatment of solitary fibrous tumor and Hemangiopericytoma (10) Concomitant Use of Bevacizumab Avastin® Avastin® will NOT be used to treat a single condition when the individual is also receiving other targeted biologic agents (including, but not limited to erlotinib, cetuximab, panitumumab, trastuzumab, lapatinib, and ziv-aflibercept) Other (11) Other Indication not otherwise specified (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 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 . 4 REVIEW REQUEST FOR Bevacizumab (Avastin®) For Non-Ophthalmologic Indications Provider Data Collection Tool Based on Medical Policy DRUG.00038 Complete this form in its entirety and fax to UM Call Center 404-848-2448 Policy Last Review Date: 11/05/2015 Policy Effective Date 01/05/2016 Provider Tool Effective Date 01/05/2016 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. 5