Download Halaven - Anthem

REVIEW REQUEST FOR
Eribulin mesylate (Halaven®) - Oncology
Provider Data Collection Tool Based on Medical Policy DRUG.00048
Policy Last Review Date:
11/03/2016
Policy Effective Date:
Request Date:
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Initial Authorization Request
Buy and bill
11/17/2016
Provider Tool Effective Date:
Subsequent Request
Individual’s Name:
Date of Birth:
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/
Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
11/17/2016
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:
Eribulin mesylate (Halaven®)
J9179
Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
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/
Duration:
Start Date For This Request:
(Weeks)
/
/
(mg/m2)
(Other)
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. Breast cancer
Individual has locally recurrent or metastatic breast cancer (If checked, mark the following that apply to the individual)
Halaven™ will be used as single agent
Halaven™ will be used in a single line of therapy
Individual has previously received at least two chemotherapeutic regimens for locally recurrent or metastatic disease
Other
Individual has locally recurrent or metastatic HER2+ breast cancer (If checked, mark the following that apply to the individual)
Individual has symptomatic visceral disease
Individual has hormone receptor-negative disease
Individual has hormone receptor-negative disease
Individual has hormone receptor-positive and endocrine refractory disease
REVIEW REQUEST FOR
Plan Logo
Eribulin mesylate (Halaven®) - Oncology
Provider Data Collection Tool Based on Medical Policy DRUG.00048
Policy Last Review Date:
11/03/2016
Policy Effective Date:
11/17/2016
Provider Tool Effective Date:
11/17/2016
2. Soft tissue Sarcoma
Individual has locally recurrent or metastatic soft tissue sarcoma
Halaven™ will be used as single agent
Halaven™ will be used in a single line of therapy
Individual has previously received at least two chemotherapeutic regimens for locally recurrent or metastatic disease
Other
3. Other Use(s) (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 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.
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/
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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