Prior Auth Form Page Number

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1 Prior Auth Form Page Number B vs D Oral Anti-Cancer 3 B vs D Oral Anti-Emetic 4 B vs D Oral Anti-rejection/Transplant 5 J0129 Abatacept, inj Orencia 6 J0180 Agalsidase beta injection Fabrazyme 7 J0205 Alglucerase injection Ceredase 8 J0215 Alefacept Amevive 9 J0220 Alglucosidase alfa inj Myozyme 46 J0256 Alpha 1 proteinase inhibitor Aralast, Prolastin, Zemaira 10 J0585 Botulinum toxin a per unit Botox 11 J0587 Botulinum toxin type B Myobloc 12 J0800 Corticotropin injection Acthar gel 13 J0881 Darbepoetin alfa, non-esrd Aranesp J0894 Decitabine, inj Dacogen 16 J1300 Eculizumab inj Soliris 17 J1458 Galsulfase, inj Naglazyme 18 J1459-J1573 IVIG 46 J1743 Idursulfase inj Elaprase 19 J1785 Injection imiglucerase /unit Cerezyme 20 J1931 Laronidase injection Aldurazyme 21 J2323 Natalizumab injection Tysabri 46 J2353 Octreotide injection, depot Sandostatin LAR 46 J2354 Octreotide inj, non-depot Sandostatin 46 J2503 Pegaptanib sodium injection Macugen 22 J2504 Pegademase bovine, 25 iu Adagen 23 J2778 Ranibizumab inj Lucentis 24 J3396 Verteporfin injection Visudyne 25 J3487 Zoledronic acid Zometa 26 J7186-J7198 Factor Products 46 J7310 Ganciclovir long act implant Vitrasert 46 J7311 Fluocinolone acetonide implt Retisert 46 J9001 Doxorubicin hcl liposome inj Doxil 27 J9010 Alemtuzumab injection Campath 28 J9015 Aldesleukin/single use vial Proleukin 29 7/2010 1

2 J9033 Bendamustine injection Treanda 46 J9035 Bevacizumab injection Avastin 30 J9041 Bortezomib injection Velcade 31 J9055 Cetuximab injection Erbitux 46 J9201 Gemcitabine HCl Gemzar 32 J9207 Ixabepilone injection Ixempra 33 J9211 Idarubicin hcl injection Idamycin 34 J9261 Nelarabine injection Arranon 35 J9264 Paclitaxel protein bound Abraxane 36 J9266 Pegaspargase/singl dose vial Oncaspar 37 J9268 Pentostatin injection Nipent 38 J9300 Gemtuzumab ozogamicin Mylotarg 39 J9310 Rituximab cancer treatment Rituxan 40 J9350 Topotecan Hycamtin 41 J9355 Trastuzumab Herceptin 42 J9390 Vinorelbine tartrate/10 mg Navelbine 43 J9395 Injection, Fulvestrant Faslodex 44 J9600 Porfimer sodium Photofrin 45 7/2010 2

3 Oral Anti-Cancer Medications Part B vs. Part D (Busulfan, Capecitabine, Cyclophosphamide, Etoposide, Melphalan, Methotrexate, Temozolomide, Topotecan) Name: Name: Tax ID# ID number: Date of Birth: Address: Home Phone: City: State: ZIP code: Address: Phone: Fax: City: State: ZIP code: Is the requested medication being prescribed for the treatment of cancer? Is the drug a full therapeutic replacement for an intravenous chemotherapy drug that would otherwise have been administered to treat this condition? Duration of therapy requesting: RPh RPh MD Approved Denied Date 7/2010 3

4 Oral Antiemetic Part B versus Part D Determination (Aprepitant, Chlorpromazine, Dexamethasone, Diphenhydramine, Dolasetron, Dronabinol, Granisetron, Hydroxyzine, Nabilone, Ondansetron, Perphenazine, Prochlorperazine, Promethazine, Thiethylperazine, Trimethobenzamide, etc.) Where is chemotherapy being administered? Is the drug part of a cancer chemotherapy regimen? ICD-9 Code: J-Code: Is the drug a full therapeutic replacement for an intravenous antiemetic drug that would otherwise have been administered at the time of the chemotherapy treatment? Aprepitant and Dexamethasone only Will all requested doses be administered within 2 hours before or 48 hours after chemotherapy treatment? Is this part of a 3 drug combination with a 5-HT3 antagonist? Which of the following agents are included in the chemotherapy regimen? (must be at least 1) Carmustine Mechlorethamine Cisplatin Streptozocin Cyclophosphamide Doxorubicin Dacarbazine Epirubicin Lomustine For dolasetron and granisetron will the dose exceed an initial loading dose and 24 hours of theapy? ***For Part B coverage of antiemetic, the chemotherapy must not be an oral treatment or an IV treatment given in the home setting Duration of therapy requesting: Determination Part B Part D RPh RPh Date 7/2010 4

5 Transplant Immunosuppressant Part B versus Part D Determination (tacrolimus, sirolimus, mycophenolate, cyclosporine, azathioprine, corticosteroids, etc.) Name: Name: Tax ID# ID number: Date of Birth: Address: Home Phone: City: State: ZIP code: Address: Phone: Fax: City: State: ZIP code: ICD-9 Code: J-Code: Was the members transplant covered in whole or in part by Medicare (was the Medicare a primary OR secondary payer)? Date of Transplant: Duration of therapy requesting: Determination Part B Part D RPh RPh Date 7/2010 5

6 Orencia (abatacept) Has the member previously had an inadequate response to at least 2 DMARD regimens (at least one including methotrexate)? Yes No Has there been at least 20% improvement in affected joint count? Has there been at least 20% improvement in three of the following? a. Patient s global assessment b. Physician s global assessment c. Patient s assessment of pain d. Degree of disability e. Acute-phase reactant (ESR or CRP) Does the member have any of the following? Clinically active infection? History of TB or positive PPD? Has the member failed Remicade? _ Concurrent treatment with any other biological RA therapy? Units Date 7/2010 6

7 Fabrazyme (Agalsidase) Fabry Disease other Does the member have a diagnosis of Fabry disease and require enzyme replacement? If no, Please provide journal articles supporting the off-label use that is being requested. Units Date 7/2010 7

8 Ceredase (alglucerase) Does the member have Gaucher s disease (type 1) and require enzyme replacement? If no, Please provide journal articles supporting the off-label use that is being requested. Units Date 7/2010 8

9 Amevive (alefacept) Please complete the following for Re-Authorization: Has the member achieved a scoring of almost clear by Physician Global Assessment (PGA)? Is the member s CD4+ T-Lymphocyte cell count > 250 cells/ul**? Moderate to Severe Plaque Psoriasis What percentage of body surface is involved? % (>10%) Has the member had an inadequate response **Please complete the following laboratory information: CD4+ T-Lymphocyte cell count: cells/ul Has it been at least 12 weeks since completion of the last phototherapy? treatment? Has the member had an inadequate response systemic Date of last treatment with alefacept: therapy? Is the member s CD4+ T-Lymphocyte cell count > 250 cells/ul**? **Please complete the following laboratory information: CD4+ T-Lymphocyte cell count: cells/ul Has the member previously been treated with Amevive (alefacept) If yes, please provide date of last treatment: Initial requests will only be given for 12 weeks of therapy (12 doses) Units Date 7/2010 9

10 alpha- 1 proteinase inhibitor (Aralast, Prolastin, Zemaira ) Is the member s serum - 1 AT level <11umol/L or <80 mg/dl (commercial standard procedure)? serum - 1 AT level: umol/l OR - mg/dl If yes, has the serum alpha- 1 antitrypsin level been maintained at > 11 umol/l (or > 80 mg/dl commercial standard)? Current alpha- 1 antitrypsin level: Does the member have a congenital deficiency of alpha- 1 PI (alpha- 1- antitrypsin deficiency)? Has diagnosis been confirmed by genomic DNA analysis demonstrating PiZZ, PiZ(null), or Pi(null)(null) phenotypes? Does the member have clinically demonstrable emphysema? Is the member s FEV 1 (% predicted) >30% and <65%? FEV 1 value: % OR Has there been a rapid decline in lung function (change in FEV 1 >120ml/yr)? Is the member a nonsmoker or ex-smoker? Aralast Prolastin Zemaira Units Date 7/

11 Botulinum Toxin A (Botox) ICD-9 Code: J-Code: Chronic Anal Fissure Is this a reauthorization Has the member had an inadequate response to at least two of If yes, attach chart documentation that clearly indicates clinical the following: sitz baths, bulk forming laxatives, topical nitrates, improvement (Required) topical analgesics, emollient suppositories, oral or topical Date of last injection calcium channel blockers? Neuromuscular Disorders Other appropriate diagnoses Approved for the following criteria: Sialorrhea Strabismus and blepharospasm associated with dystonia Benign essential blepharospasm Severe primary hyperhidrosis VII cranial nerve disorders (hemifacial spasms) Has the member failed topical therapy? Cervical dystonia Urinary incontinence in patients using clean intermittent Spastic Torticollis Muscle spasticity as a result of CNS disorder or injury catheterization that has failed anticholinergic treatment Oromandibular dystonia Please document any inadequate response to prior Focal hand dystonia - writer s & musician s cramp therapy please list drug and dates of usage: Achalasia Approved based on any of the following criteria: Does member have a high risk of complication from pneumatic _ dilation or surgical myotomy? Has the member had a failure to prior pneumatic dilation or surgical myotomy? _ Has the member had prior dilation caused esophageal Physical therapy attempted perforation? Dates of Therapy: to Has the member had an epiphrenic diverticulum or hiatal hernia? RPh RPh MD Approved Denied Units (1 unit) Date intended recipient 7/2010of this information, you are hereby notified that any disclosure, copying, or distribution of this information is strictly prohibited. If you have 11 received

12 Botulinum Toxin B (Myobloc) ICD-9 Code: J-Code: Is this a reauthorization If yes, attach chart documentation that clearly indicates clinical improvement (Required) Date of last injection Neuromuscular Disorders Approved for the following criteria: Strabismus and blepharospasm associated with dystonia Benign essential blepharospasm VII cranial nerve disorders (hemifacial spasms) Cervical dystonia Spastic Torticollis Muscle spasticity as a result of CNS disorder or injury Oromandibular dystonia Focal hand dystonia - writer s & musician s cramp Achalasia Approved based on any of the following criteria: Does member have a high risk of complication from pneumatic dilation or surgical myotomy? Has the member had a failure to prior pneumatic dilation or surgical myotomy? Has the member had prior dilation caused esophageal perforation? Has the member had an epiphrenic diverticulum or hiatal hernia? Chronic Anal Fissure Has the member had an inadequate response to at least two of the following: sitz baths, bulk forming laxatives, topical nitrates, topical analgesics, emollient suppositories, oral or topical calcium channel blockers? Other appropriate diagnoses Sialorrhea Severe primary hyperhidrosis Has the member failed topical therapy? Urinary incontinence in patients using clean intermittent catheterization that has failed anticholinergic treatment Please document any inadequate response to prior therapy please list drug and dates of usage: Physical therapy attempted Dates of Therapy: to RPh RPh MD Approved Denied Units (100 units) Date 7/

13 Corticotropin (Acthar H.P.) Myasthenia gravis Multiple sclerosis Please list all known allergies: RPh RPh MD Approved Denied Units (40 units) Date 7/

14 Aranesp (darbepoetin alpha) The member has anemia associated with which of the following: chronic renal failure ICD-9 Code: J-Code: cancer patients on chemotherapy Required laboratory results within past 4 weeks Transferrin (TSat%) > 20% : % Ferritin > 100 ng/dl : ng/dl Hemoglobin < 11 g/dl : g/dl OR Hematocrit < 33% : % Date of above labs: For MDS and Zidovudine related anemia Provide results of serum EPO: EPO: mu/ml Serum Epo must be less than 500 mu/ml Is the member on myelosuppressive chemotherapy? Yes No Is the anticipated outcome of chemotherapy curative? Yes No Is hemoglobin less than 10 g/dl? Yes No allogeneic blood transfusion in surgery patients Management of Hepatitis C with combination of ribavirin and interferon or peg-interferon Zidovudine therapy in HIV Zidovudine dose (g/day) (commonly associated with doses >1.5 g/day) Myelodysplastic Syndrome (MDS) Have other causes of anemia been ruled out? (i.e. blood loss, B-12, folate deficiencies, hemolysis, and bleeding)? attach supporting documentation RPh RPh MD Approved Denied Units (1mcg) date 7/

15 Aranesp Re-Authorization Form Please select all that apply to verify effectiveness of therapy (must be at least one): Verification that Hct reached target range (30-36%) Decrease in blood transfusions Hgb 1g/dL from pre-treatment level Please attach supporting labs and/or chart documentation Required laboratory results within past 4 weeks Transferrin (TSat%) > 20% : % Ferritin > 100 ng/dl : ng/dl Hemoglobin g/dl Hematocrit % Date of above labs: Patients baseline Hgb (prior to Epo): g/dl Please indicate the highest Hgb since initiation of therapy with Epo: Hgb: g/dl If Hgb has reached 12 g/dl, has there been a dose reduction? Yes No **Please note continuation will not be approved if Hgb has reached 12g/dL without a dose reduction** Please verify that average Hct was below 36% over the previous 3 months: Provide lab results below Date Hct (%) For all drug-induced anemia re-authorizations, please complete the following for the causative agent and verify that therapy is still ongoing Drug: Is member still receiving therapy with causative agent? Expected duration of therapy Yes No RPh RPh MD Approved Denied Units (1 mcg) date 7/

16 Dacogen (decitabine) Myelodysplastic syndrome Acute Myeloid Leukemia Chronic Myeloid Leukemia Please list all known drug allergies Units Date 7/

17 Soliris (eculizumab) Does the member have a diagnosis of paroxysmal nocturnal hemoglobinuria? Has the member received the meningococcal vaccine at least 2 weeks prior to start of therapy? Date of completion: Units Date 7/

18 Naglazyme (galsulfase) mucopolysaccharidosis VI other Please attach any clinical information relative to diagnosis and supportive documentation if any diagnosis other than what is listed and FDA approved. Please list all known drug allergies Units (1 mg) Date 7/

19 Elaprase (idursulfase) mucopolysaccharidosis II other Please attach any clinical information relative to diagnosis and supportive documentation if any diagnosis other than what is listed and FDA approved. Please list all known drug allergies Units (1 mg) Date 7/

20 Cerezyme (imiglucerase) Bone disease, involving recurrent or acute crises of pain with objective documentation (e.g. MRI, bone scan, X-ray, or expert opinion of a rheumatologist or orthopedist), spinal compression or evidence of other serious changes on x-ray even in the absence of pain Please attach associated documentation Type I Gauchers Disease Does the member have a confirmed diagnosis of TI Gauchers Disease? Please document that the patient has one or more of the following: Moderate to severe anemia (Hgb < 12g/dL in males, Hgb < 11g/dL in females and children) after exclusion of other causes, such as iron deficiency Please attach Hgb, Hct, ferritin, and Tsat levels Thrombocytopenia (platelets < 120,000 cells/mm 3 ) with bleeding tendency, or consistently decreasing platelet count Please attach most recent platelet count Significant hepatomegaly, (liver volume > 1.25 times normal volume) Please attach supporting documentation Significant splenomegaly, (splenic volume > 5 times normal volume) Please attach supporting documentation For Reauthorization Please attach baseline information and documentation of an improvement in one or more of above listed clinical values that represent symptomatic Gauchers Disease ALL Other Indications See below for medical necessity review documentation Units Date 7/

21 Aldurazyme (laronidase) Does the member have one of the following? Hurler form of Mucopolysaccharidosis I Hurler-Scheie form of Mucopolysaccharidosis I (MPS I) Scheie form of Mucopolysaccharidosis I (MPS I) and moderate to severe symptoms Units Date 7/

22 Macugen (pegaptanib) Please check the appropriate diagnosis below: neovascular (wet) age-related macular degeneration Other: Does the patient have an ocular or periocular infection? Macugen RPh RPh MD Approved Denied Units (0.3 mg) Date 7/

23 Adagen (pegademase bovine) Please provide baseline Plasma ADA activity level ADA: micromole/hour/ml Yes No Does the member have a diagnosis of severe combined immunodeficiency disease? Yes No Does the member have adenosine deaminase (ADA) deficiency? Yes No Please provide baseline Red Cell datp Red cell datp: micromole/ml For all other indications, please provide statement of medical necessity and medical literate as requested below. Duration of therapy requesting: Units Date 7/

24 Lucentis (ranibizumab) Please check the appropriate diagnosis below: neovascular (wet) age-related macular degeneration Other: Does the patient have an ocular or periocular infection? Lucentis RPh RPh MD Approved Denied Units (0.1 mg) Date 7/

25 Visudyne (verteporfin) ICD-9 Code: J-Code: Please check the appropriate diagnosis below: Does the patient have an ocular or periocular infection? neovascular (wet) age-related macular degeneration presumed ocular histoplasmosis pathologic myopia Other: Visudyne RPh RPh MD Approved Denied Units (0.1 mg) Date 7/

26 Zometa (zolendronic acid) Hypercalcemia of Malignancy Is albumin-corrected calcium > 12 mg/dl? ICD-9 Code(s): J-Code: Date Albumin Calcium Corrected Calcium Please provide date of last infusion: Please select the appropriate indication below Bone metastasis of solid tumor origin Metastatic Bone Disease hypercalcemia of malignancy Please indicate origin of metastasis: multiple myeloma prostate cancer after treatment failure with at least one Please complete for all indications: hormonal therapy Is the patient on a calcium and vitamin D supplement? osteopenia secondary to androgen deprivation therapy in prostate cancer patients Is the patient s creatinine clearance > 30 ml/min? osteopenia secondary to hormone therapy in breast cancer patients osteopenia secondary to ovarian dysfunction induced Please attach most recent DEXA results and baseline results (if applicable). by chemotherapy in premenopausal women with early stage breast cancer Other RPh RPh MD Approved Denied Units (1 mg) Date 7/

27 Doxil (doxorubicin liposomal) ICD-9 Code: J-Code: Please indication the members diagnosis Breast cancer Fallopian tube carcinoma Primary peritoneal carcinoma Sarcoma Multiple myeloma Cervical Cancer Has the member failed previous treatment? AIDS related Kaposi s sarcoma Has the member progressed on previous therapy? Ovarian Cancer Has the member previously been treated with platinum based therapy? Units (10 mg)date 7/

28 Campath (alemtuzumab) B cell Chronic Lymphocytic Leukemia Is the lymphoma stage II-IV? Yes No Is the member greater than 70 years old? Yes No Other Non Hodgkins Lymphomas Has the member failed previous treatment? Yes No Please Attach Pathology Reports Units (10mg) Date 7/

29 Proleukin (aldesleukin) Does the member have an ECOG < 1? Does the member have untreated brain metastasis? Renal Cell Cancer Does the member have stage IV unresectable disease? Melanoma Does the member have stage III-IV disease? Units (1 vial) Date 7/

30 Avastin (bevacizumab) Renal Cell Carcinoma Does the member have metastatic disease? Glioblastoma Has the member been treated previously with temozolomide? Colorectal Cancer Does the member have metastases? Will the treatment be in combination with 5-FU? Non-Small Cell Lung Cancer Does the member have unresectable, locally advanced, recurrent or metastatic NSCLC? Will the treatment be in combination with paclitaxel and carboplatin? Breast Cancer Does the member have metastatic or recurrent, HER-2 negative disease? Will the treatment be in combination with paclitaxel? Units Date 7/

31 Velcade (bortezomib) ICD-9 Code: J-Code: Multiple Myeloma If initial therapy, is it being used in combination with other medications? Has the member failed any other treatments? Peripheral T Cell Lymphoma Does the member have relapsed or refractory disease? Is the member a candidate for autologous stem cell transplant? Follicular B Cell Non-Hodgkins Lymphoma Does the member have relapsed or refractory disease? Mantle Cell Lymphoma Does the member have relapsed, refractory, or progressive disease? Units (0.1mg) Date 7/

32 Gemzar (gemcitabine) ICD-9 Code: J-Code: Please select the appropriate diagnosis: o Metastatic breast cancer o Locally-advanced NSCLC o Metastatic NSCLC o Pancreatic cancer o Advanced or relapsed ovarian cancer o Bladder cancer o Cervical cancer o Hodgkin s disease o Small cell lung cancer o Hepatobiliary cancer o carcinoma of gallbladder o cervical cancer o germ cell tumors o testicular cancer o head and neck cancer, o Hodgkin's disease o Non-Hodgkin's lymphoma o Kaposi's sarcoma o soft tissue sarcoma or medi al e essit reviews ou must provide peer reviewed our al arti les to support a re uest or o label use Please atta a medi al i ormatio t at ma support approval Please document complete chemotherapy regimen being used for this patient: Units Date intended recipient of this information, you are hereby notified that any disclosure, copying, or distribution of this information is strictly prohibited. If you have received this message in error please immediately notify the sender by telephone to arrange for its return. 7/

33 Ixempra (ixabepilone) ICD-9 Code: J-Code: Please confirm that patient s neutrophil count is greater than 1500 cells/mm 3 ANC: Please confirm that patient s platelet count is greater than 100,000 cells/mm 3 Plt: Does the member have locally advanced or metastatic breast cancer? Yes No Will this be given in combination with 5-FU or Xeloda Has the member been previously treated with a taxane AND an anthracycline or have a contraindication to their use? (capecitabine)? Yes No (max dose is 88 mg) Units (1mg) Date 7/

34 Idamycin (idarubicin) Is this medication being used as part of a combination chemotherapy ICD-9 Code: J-Code: Please indicate appropriate diagnosis below: Acute myeloid leukemia Acute nonlymphocytic leukemia Acute Acute lymphoblastic leukemia Chronic myelogenous leukemia Breast Cancer regimen? Please document complete regimen: Units (5mg) Date 7/

35 Arranon (nelarabine) Does the member have relapsed or refractory T-cell acute lymphoblastic leukemia (ALL)? Does the member have T-cell lymphoblastic lymphoma? For ALL other indications please submit documentation to support the use of nelarabine for a medical necessity review Units Date 7/

36 Abraxane (paclitaxel, albumin bound) ICD-9 Code: J-Code: Please confirm that patient s neutrophil count is greater than 1500 cells/mm 3 ANC: Please indicate appropriate diagnosis below: anal cancer head/neck cancer recurrent or metastatic breast cancer Has member previously been treated with an anthracycline? Yes No If no, please document if there is a contraindication to therapy If yes, please document below. Units (1mg) Date 7/

37 Oncaspar (pegaspargase) ICD-9 Code: J-Code: Does the member have a diagnosis of ALL acute lymphocytic leukemia? Did the member previously have hypersensitivity to L-asparginase? Will this medication be used in combination with other chemotherapy agents? Please document currently planned regimen: Units Date 7/

38 Nipent (pentostatin) Please indicate appropriate indication: Hairy cell leukemia Chronic lymphoid leukemia Prolymphocytic leukemia Primary cutaneous lymphoma Units Date 7/

39 Mylotarg (gemtuzumab) AML ICD-9 Code: J-Code: Does the member have CD33 positive AML? Yes No Has the member experienced a relapse of disease? Yes No Units Date 7/

40 Rituxan (rituximab) ICD-9 Code: J-Code: Non-Hodgkins Lymphoma Is the lymphoma B-cell/CD-20 positive? Rheumatoid Arthritis Member has at least 6 swollen and tender joints Chronic Lymphocytic Leukemia (CLL) Is the member stage II-IV and using first line? Member has > 45 minutes of morning stiffness Has the member previously had an inadequate response to methotrexate alone or in combination with other DMARDs in a trial lasting > 3 months? Has the member previously had an inadequate response to at least 2 DMARD regimens (at least one including methotrexate)? Does the member have any of the following? Clinically active infection? History of TB or positive PPD? Concurrent treatment with other biological DMARD? Yes No Has the member relapsed and using in combination with fludarabine, cyclophosphamide, or chlorambucil? Please attach pathology report or er Has the member failed Remicade? cat o Patient current weight: RPh RPh MD Approved Denied Units (100mg) Date this message in error please immediately notify the sender by telephone to arrange for its return 7/

41 Hycamtin (topotecan) CNS lymphoma Has the member previously been treated with another agent? ICD-9 Code: J-Code: Yes No Please confirm that patient s neutrophil count is greater Has the member had whole brain radiation? Yes No than 1500 cells/mm 3 ANC: Please confirm that patient s platelet count is greater than Please check an indication below if applicable: 100,000 cells/mm 3 Plt: Non small cell lung cancer Ovarian Cancer Does the member have recurrent, platinum resistant Myelodysplastic syndrome Chronic myelomonocytic leukemia disease? Yes No Nephroblastoma Small cell lung cancer Other (please attach Has the member previously been successfully treated with documentation to facilitate a medical necessity review) another agent? Yes No Cervical Cancer Does the member have recurrent, stage IV, or persistent disease that is not amenable to curative treatment w/ surgery or radiation? Yes No Is this being used in combination with cisplatin? Yes No Non Melanoma skin cancers Does the member have metastatic disease or a disseminated recurrence? Yes No Units (4mg) Date 7/

42 Herceptin (trastuzumab) Please select appropriate treatment option below: Monotherapy for the treatment of metastatic breast cancer that has relapsed following prior chemotherapy Combination with paclitaxel for the initial treatment of Breast Cancer metastatic breast cancer Does member have overexpression** of HER2 protien? Combination with adjuvant chemotherapy (i.e. doxorubicin and cyclophosphamide, or paclitaxel) in surgically removed cate y R or a pl e breast cancer Attach res lts Has the member had a baseline cardiac evaluation including history, physical and one of the following: Electrocardiogram (EKG) Echocardiogram Multiple gated acquisition angiopraphy (MUGA scan) Attach chart oc e tat o Please document currently planned regimen: RPh RPh MD Approved Denied Units (10mg) Date 7/

43 Navelbine (vinorelbine) Does the member have any hepatic insufficiency? If yes, has the dose been adjusted as recommended? For ALL other indications please submit documentation to support the use of vinorelbine for a medical necessity review Please select the most appropriate diagnosis Non-small cell lung cancer (NSCLC) Small cell carcinoma of lung Breast cancer Cervical cancer Ovarian cancer Esophageal cancer Carcinoma of cervix Head and neck cancer Hodgkin's disease Kaposi's sarcoma Non-Hodgkin's lymphoma Soft tissue sarcomas Hormone refractory prostate cancer Units Date 7/

44 Faslodex (fulvestrant) ICD-9 Code: J-Code: Does the patient have a diagnosis of metastatic breast cancer? Is the member post-menopausal or male? Is the cancer hormone receptor positive? Has the member experienced disease progression following anti-estrogen therapy? yes spec y pre o s treat e t Please Document Current treatment: Units Date 7/

45 Photofrin (porfimer) Barrett s Esophagus Does the member have high grade dysplasia? Yes No Will the member undergo esophagectomy? Yes No Yes No ay o ly e co s ere p to co rses Esophageal Cancer Does member have obstructing carcinoma? Yes No Non melanoma skin cancer Is surgery contraindicated or impractical? Yes No Non small cell lung cancer Does member have endobronchial invasive carcinoma? Yes No Does member have obstructing carcinoma? Yes No Is surgery contraindicated or impractical? Yes No Units Date 7/

46 Universal Prior Authorization Form Please list all known drug allergies Units Date 7/