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Lupron Hormonal Therapy Prior Authorization Request Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-855-330-1720 CVS Caremark administers the prescription benefit plan for the patient identified. This patient’s benefit plan requires prior authorization for certain medications in order for the drug to be covered. To make an appropriate determination, providing the most accurate diagnosis for the use of the prescribed medication is necessary. Please respond below and fax this form to CVS Caremark toll-free at 1-855-330-1720. If you have questions regarding the prior authorization, please contact CVS Caremark at 1-866-814-5506. For inquiries or questions related to the patient’s eligibility, drug copay or medication delivery; please contact the Specialty Customer Care Team: CaremarkConnect® 1-800-237-2767. Patient’s Name: _____________________________ Date: ________________________________ Patient’s ID: _______________________________ Patient’s Date of Birth: ________________ Physician’s Name: _______________________________________________________________________ Specialty: _________________________________ NPI#: ________________________________ Physician Office Telephone: __________________ Physician Office Fax: ___________________ Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines. Additional Demographic Information: Patient Weight: _________________________kg Patient Height: ft inches Criteria Questions: 1. Which drug and strength is being prescribed? Lupron Depot 7.5 mg Lupron-PED Depot 7.5 mg Lupron Depot-3 month 22.5 mg Lupron-PED Depot 11.25 mg Lupron Depot-4 month 30 mg Lupron-PED Depot 15 mg Lupron Depot-6 month 45 mg Lupron-PED Depot 30 mg Lupron Depot 3.75 mg Leuprolide (Leuprolide acetate) Lupron Depot-3 month 11.25 mg Lupaneta Pack Other _____________________________________________ Indicate prescribed dose and frequency: _________________________________________________________ 2. What is the requested drug being used for? Infertility Uterine fibroids Endometriosis Ovarian cancer Prostate cancer Breast cancer Fallopian tube cancer Primary peritoneal cancer Central precocious puberty (CPP) Use as stimulation test to confirm diagnosis of central precocious puberty (CPP) Treatment of advancing puberty and growth failure Other _____________________________________________ 3. What is the ICD-10 code? _____________ 4. What is the patient's gender? Female 5. Does the patient have UNDIAGNOSED abnormal vaginal bleeding? Yes No Not applicable 6. Have pregnancy and breastfeeding been excluded? Yes No Male If Male, skip to diagnosis section. Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended recipient you hereby are advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received the fax in error, please immediately notify the sender by telephone and destroy the original fax message. Lupron Hormonal SGM - 8/2016. CVS Caremark is an independent company that provides pharmacy benefit management services to CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. members. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc. Page 1 of 3 Complete the following section based on the patient's diagnosis. Section A: Central Precocious Puberty 7. What is the prescribed treatment schedule? 1-month administration 3-month administration Other ______________________________ 8. Is the patient currently receiving the prescribed therapy for central precocious puberty? If Yes, no further questions Yes No 9. Has the diagnosis of central precocious puberty been confirmed by a pubertal response to a GnRH agonist test or a pubertal level of a third generation LH assay? Yes No ACTION REQUIRED: Attach documentation of LH level from GnRH agonist test or a third generation LH assay. 10. Has the diagnosis been confirmed by assessment of bone age versus chronological age? Yes No 11. Has appropriate diagnostic imaging of the brain been done to exclude an intracranial tumor? Yes No 12. How old was the patient AT THE ONSET of secondary sexual characteristics? ________________ years Section B: Prostate Cancer 13. Will the prescribed agent be used as neoadjuvant therapy prior to radical prostatectomy? Yes No 14. Does the patient have a lymph node-positive disease that was found during pelvic lymph node dissection (PLND)? Yes No If No, skip to #17 15. Will the prescribed agent be used as adjuvant therapy? Yes No 16. Will the prescribed agent be used in combination with external beam radiation therapy (EBRT)? Yes No If No, no further questions 17. What disease patient have: Metastatic Regional Recurrent Progressive castration-naïve, no further questions None of the others, skip to #20 18. If metastatic or regional disease, will the prescribed agent be used as initial androgen deprivation therapy (ADT)? Yes No No further questions 19. If recurrent disease, has the patient experienced biochemical failure after previous therapy? Yes No No further questions 20. What is the disease’s risk stratification? Very low Low Intermediate High Very High 21. Will the prescribed agent be used as initial ADT? Yes No 22. If very high, is the patient a candidate for definitive therapy? If Yes, skip to #24 Yes No 23. If Intermediate or very high, will the prescribed agent be used in combination with EBRT? Yes No 24. If high or very high, what is the prescribed regimen? Prescribed agent + EBRT Prescribed agent + EBRT + docetaxel Other ___________________________ Section C: Breast Cancer 25. Is the patient premenopausal? Yes No 26. Is breast cancer hormone receptor positive? Yes No Section D: Infertility 27. Is leuprolide requested to prevent premature LH surges in a woman undergoing assisted reproductive technology (ART) program? If Yes, document ART therapy patient is undergoing. Yes No In vitro fertilization (IVF) Gamete intra-fallopian transfer (GIFT) Zygote intra-fallopian transfer (ZIFT) Tubal embryo transfer (TET) Frozen embryo transfer (FET) Donor embryo cycles Other ________________________________ Section E: Uterine Fibroids 28. Has the patient received previous therapy with Lupron Depot or Lupaneta Pack? Yes No If No, skip to #31 Page 2 of 3 29. How long has the patient received prior therapy with Lupron Depot and Lupaneta Pack? _________ months Document dates and doses received: ____________________________________________________________ __________________________________________________________________________________________ 30. If less than 6 months of therapy received, has the patient been determined to have a bone mineral density within normal limits? Yes No Document date of DEXA scan: ________________ 31. Does the patient have a diagnosis of anemia? Yes No Provide at least one lab value and date drawn: Hematocrit (Hct): ________________ % Date drawn: ________________ Hemoglobin (Hgb): ________________ g/dL Date drawn: ________________ 32. Will Lupron Depot be used in the preoperative setting to facilitate surgery? Yes No 33. Will Lupron Depot be used in conjunction with iron therapy? Yes No Section F: Endometriosis 34. Has the patient received previous therapy with Lupron Depot or Lupaneta Pack? Yes No If No, no further questions. 35. How long has the patient received previous therapy with Lupron Depot and Lupaneta Pack therapy? ______ months Document dates and doses received: ____________________________________________________________ __________________________________________________________________________________________ 36. If patient has received between 6 and 12 months of therapy, has the patient had a recurrence of symptoms? Yes No Not applicable, no further questions 37. Has the patient been determined to have a bone mineral density within normal limits? Yes No Document date of DEXA scan: ________________ 38. If Lupron Depot is being prescribed, will the patient be receiving add-back therapy (e.g., norethindrone) in addition to Lupron Depot? Yes No Section G: Fallopian Tube Cancer, Primary Peritoneal Cancer and Ovarian Cancer 39. If patient's diagnosis is ovarian cancer, what is the tumor type? Ovarian stromal tumor, No further questions Epithelial ovarian cancer Other _____________________________________________ 40. Does the patient have persistent or recurrent disease? Yes No 41. Will Lupron Depot be used as a single agent? Yes No Section H: Treatment of Advancing Puberty and Growth Failure 42. Is the patient a child with advancing puberty? Yes No 43. Is the patient also requesting OR is currently receiving growth hormone? Yes No I attest that this information is accurate and true, and that documentation supporting this information is available for review if requested by CVS Caremark or the benefit plan sponsor. X_______________________________________________________________________ Prescriber or Authorized Signature Date (mm/dd/yy) Page 3 of 3