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Member Name: {{MEMFIRST}} {{MEMLAST}} DOB: {{MEMBERDOB}} PA Number: {{PANUMBER}} Lupron Hormonal Therapy Prior Authorization Request 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 1-866-249-6155. 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 Name: Patient’s ID: Physician’s Name: Specialty: _________________________________, Physician Office Telephone: Date: Patient’s Date of Birth: NPI#: ___________________________ Physician Office Fax: 1. Which drug and strength is being prescribed? Lupron Depot 7.5mg Lupron-PED Depot 7.5mg Lupron Depot 22.5mg Lupron-PED Depot 11.25mg Lupron Depot 30mg Lupron-PED Depot 15mg Lupron Depot 45mg Lupron-PED Depot 30mg Leuprolide (Leuprolide acetate, Lupron microdose, Lupron 2 week kit) Lupron Depot 3.75mg Lupron Depot 11.25mg Other ___________________________________ 2. What is Lupron being used for? Infertility Uterine fibroids Endometriosis Ovarian cancer Prostate cancer Breast cancer Treatment of children with central precocious puberty (CPP) Use as stimulation test to confirm diagnosis of central precocious puberty (CPP) In combination with growth hormone for a child with growth failure and advancing puberty Other ___________________________________ 3. What is the ICD9? ________________ 4. What is the gender of the patient? If Male, skip to #7 Male Female 5. Does the patient have UNDIAGNOSED abnormal vaginal bleeding? Yes No 6. Has pregnancy and breast feeding been excluded? Yes No 7. Is the patient currently on therapy with Lupron? Yes, Date started: ________________ No Complete the section designated for the patient’s diagnosis Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155 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 yo u have received the fax in error, please immediately notify the sender by telephone and destroy the original fax message. Remodulin, Tyvaso, Ventavis SGM - 9/2012 CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062 Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com Page 1 of 4 Member Name: {{MEMFIRST}} {{MEMLAST}} DOB: {{MEMBERDOB}} PA Number: {{PANUMBER}} SECTION A: Central Precocious Puberty 8. Has the diagnosis been confirmed by a pubertal response to a GnRH agonist test? Yes No 9. Has the diagnosis been confirmed by assessment of bone age versus chronological age? Yes No 10. Will discontinuation of therapy be considered at the appropriate timepoint for the onset of puberty? (i.e. 11 years of age for girls and 12 years of age for boys) Yes No 11. How old was the patient at the onset of secondary sexual characteristics? ________________ years Complete questions 12-14 if the patient is not currently on therapy. 12. Has appropriate diagnostic imaging of the brain been done to exclude an intracranial tumor? Yes No 13. Have the following been evaluated? If Yes, select below Yes No Not indicated Adrenal steroid levels to rule out congenital adrenal hyperplasia Appropriate diagnostic imaging to rule out steroid-secreting tumors 14. If the patient is a male and it is indicated, have beta human chorionic gonadotropin levels been evaluated to rule out a chorionic gonadotropin secreting tumor? Yes No Not indicated SECTION B: Prostate Cancer 15. What is the patient’s current stage of prostate cancer? Clinically localized disease Locally advanced disease No further questions Recurrent disease No further questions Metastatic (regional lymph node/distant metastases) No further questions 16. Is Leuprolide or Lupron-Depot being used as neoadjuvant androgen deprivation therapy (ADT) for radical prostatectomy? Yes No 17. Will Leuprolide or Lupron-Depot be used to shrink the large prostate to an acceptable size for brachytherapy? If Yes, no further questions Yes No 18. Is Leuprolide or Lupron-Depot being used before, during or after radiation therapy? Yes No 19. What is the risk of cancer recurrence? Low risk Intermediate risk High risk SECTION C: Breast Cancer 20. Is the patient premenopausal? Yes No 21. Is the patient pregnant right now? Yes No 22. Is breast cancer hormone receptor positive? Yes No 23. Will leuprolide be used as an adjuvant therapy? If Yes, no further questions Yes No 24. Does the patient have metastatic or recurrent disease? Yes No 25. Will leuprolide be used in combination with endocrine therapy? Yes No SECTION D: Infertility 26. Is Lupron being used to inhibit premature luteinizing hormone (LH) surge in controlled ovarian hyperstimulation (COH)? Yes No Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155 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 yo u have received the fax in error, please immediately notify the sender by telephone and destroy the original fax message. Remodulin, Tyvaso, Ventavis SGM - 9/2012 CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062 Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com Page 2 of 4 Member Name: {{MEMFIRST}} {{MEMLAST}} DOB: {{MEMBERDOB}} PA Number: {{PANUMBER}} 27. Is the patient pregnant right now? Yes No SECTION E: Uterine Fibroids 28. Does the patient have a diagnosis of anemia? (e.g., Hct less than or equal to 30% and/or Hgb less than or equal to 10 g/dL) Yes No 29. Will Lupron Depot be used in conjunction with iron therapy? Yes No SECTION F: Endometriosis 30. Has the patient received a total of two 6-month courses of Lupron Depot therapy for endometriosis? Yes No 31. Is the patient treatment naive to Lupron Depot therapy for endometriosis? If Yes, no further questions Yes No 32. Has the patient had a recurrence of symptoms? Yes No 33. Will the patient be receiving add-back therapy (e.g., norethindrone) in addition to Lupron Depot? Yes No 34. Has the patient been determined to have a bone mineral density within normal limits? Yes No SECTION G: Ovarian Cancer 35. What is the tumor type? Ovarian stromal tumor Epithelial ovarian cancer Fallopian tube cancer Primary peritoneal cancer Other ___________________________________ 36. Does the patient have relapsed stage II-IV granulosa cell tumors? Yes No 37. Is the disease stable, recurrent, or persistent with primary chemotherapy? Yes No 38. Will Lupron Depot be used as a single agent? Yes No Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155 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 yo u have received the fax in error, please immediately notify the sender by telephone and destroy the original fax message. Remodulin, Tyvaso, Ventavis SGM - 9/2012 CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062 Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com Page 3 of 4 Member Name: {{MEMFIRST}} {{MEMLAST}} DOB: {{MEMBERDOB}} PA Number: {{PANUMBER}} Information given on this form is accurate as of this date: X_______________________________________________________________________ Prescriber or Authorized Signature Date (mm/dd/yy) Send completed form to: Case Review Unit CVS Caremark Specialty Programs Fax: 1-866-249-6155 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 yo u have received the fax in error, please immediately notify the sender by telephone and destroy the original fax message. Remodulin, Tyvaso, Ventavis SGM - 9/2012 CVS Caremark Specialty Pharmacy ● 2211 Sanders Road NBT-6 ● Northbrook, IL 60062 Phone: 1-866-814-5506 ● Fax: 1-866-249-6155 ● www.caremark.com Page 4 of 4