Locoregional & advanced esophagus or esophagogastric junction cancer

Transcription

1 Eloxatin (oxaliplatin) Prior Authorization Request (For Maryland Only) Send completed form to: Case Review Unit CVS/caremark Specialty Programs Fax: 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 If you have questions regarding the prior authorization, please contact CVS/caremark at For inquiries or questions related to the patient s eligibility, drug copay or medication delivery; please contact the Specialty Customer Care Team: CaremarkConnect Patient Name: Patient s ID: Physician s Name: Specialty: Physician Office Telephone: Date: Patient s Date of Birth: NPI#: Physician Office Fax: 1. What drug is being prescribed? Eloxatin Oxaliplatin 2. What is the patient s diagnosis? Colon cancer Rectal cancer Locoregional and advanced gastric cancer Extrahepatic cholangiocarcinoma Gallbladder cancer Intrahepatic cholangiocarcinoma Pancreatic adenocarcinoma Non-Hodgkin s lymphoma Occult primary (cancer of unknown primary) Neuroendocrine tumor Ovarian cancer, epithelial tumors Ovarian cancer, germ cell tumors Ovarian cancer, other Fallopian tube cancer Primary peritoneal cancer Testicular cancer Locoregional & advanced esophagus or esophagogastric junction cancer 3. What is the ICD code? 4. Would the prescriber like to request an override of the step therapy requirement? Yes No If No, skip to #7 5. Has the member received the medication through a pharmacy or medical benefit within the past 180 days? Yes No ACTION REQUIRED: Please provide documentation to substantiate the member had a prescription paid for within the past 180 days (i.e. PBM medication history, pharmacy receipt, EOB etc.) 6. Is the medication effective in treating the member s condition? Yes No Continue to #7 and complete entire form. Complete the following section (and sub-section) based on the patient's diagnosis. Section A: Colon and Rectal Cancer 7. Which of the following indications for oxaliplatin does the member have? Advanced or metastatic disease Synchronous abdominal and/or peritoneal metastases Synchronous liver and/lung metastases Adjuvant therapy for colon cancer Metachronous metastases Adjuvant therapy for rectal cancer 8. Which of the following is applicable to the member? Locally unresectable disease Metachronous metastases Medically inoperable Resectable metachronous metastaes Unresectable synchronous metastases 9. What is the extent of primary tumor involvement based on clinical findings of the disease (i.e., clinical staging)? Tis T1 T2 T3 T4 Other Unknown 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 independent licensees of the Blue Cross and Blue Shield Association.

2 10. Is oxaliplatin being requested as initial chemotherapy? Yes No 11. What is the prescribed regimen? FOLFOX (leucovorin, fluorouracil and oxaliplatin) CapeOx (capecitabine and oxaliplatin) Oxaliplatin plus irinotecan Fluorouracil + leucovorin + oxaliplatin 12. For which of the following clinical settings is oxaliplatin being requested? Initial chemotherapy Following second progression of disease Following first progression of disease 13. Which of the following treatments has the member received previously? Oxaliplatin-based regimen(s) Both of the above Irinotecan-based regimen(s) 14. What is the clinical stage of the disease? T1, N1, M0 T1, N1, M0 T2, N1, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0 T4, N2, M0 Unknown No assessment has been made 15. What is the pathologic stage of the disease? T3, N0, M0 T4, N0, M0 T4, N1, M0 T4, N2, M0 Unknown 16. Does the member have a high-risk factor for recurrence such as ONE of the following? Poorly differentiated histology Localized perforation Less than 12 lymph nodes examined Perineural invasion Closed, or positive margins 17. Does the member have resectable metachronous metastases? Yes No 18. Has the member received previous chemotherapy for colon cancer? Yes No 19. What is the extent of primary tumor involvement (T) based on pathologic findings (i.e., pathologic staging) of the disease? Tis T1 T2 T3 T4 Other Unknown 20. Does the member have a node-positive disease? Yes No 21. Has the member received previous chemotherapy for rectal cancer? Yes No Section B: Esophageal and Esophagogastric Junction Cancers 22. For which of the following clinical settings is oxaliplatin being requested? Preoperative chemoradiation Postoperative chemotherapy Definitive chemoradiation Palliative therapy Concurrent chemoradiation 23. What is the stage of the disease? T1b, N+ T2, N0 T2, N+ T3, N0 T3, N+ T4a, N0 T4a, N+ T4b, N0 T4b, N+ 24. What is the prescribed regimen? Oxaliplatin + fluorouracil Epirubicin + oxaliplatin + capecitabine (i.e., modified ECF [EOX]) Oxaliplatin + capecitabine Epirubicin + oxaliplatin + fluorouracil (i.e., modified ECF [EOF]) Docetaxel + oxaliplatin + fluorouracil (i.e., modified DCF) Docetaxel + oxaliplatin + capecitabine (i.e., modified DCF) 25. Does the member have adenocarcinoma or noncervical esophogus squamous cell carcinoma? Yes No

3 26. Does the member have adenocarcinoma of the thoracic esophagus or esophagogastric junction? Yes No 27. Does the member have cervical esophagus squamous cell carcinoma? Yes No 28. What is the surgery status of the member? Member has declined surgery Member is medically unfit for surgery Member medically fit for surgery 29. Has the member experienced locoregional recurrence of the disease? Yes No 30. Has the member received prior surgery? Yes No 31. Has the member received prior chemoradiation? Yes No 32. Does the member have poor prognostic features? Yes No 33. Which of the following is applicable to the member? Member has declined surgery Member is medically unfit for surgery Member has persistent unresectable locally advanced, locally recurrent or metastatic disease Member has unresectable T4b tumors Member has T4b squamous cell carcinoma with invasion of the trachea, great vessels, or heart 34. Does the member have unresectable disease? Yes No 35. Has the member received preoperative modified ECF (i.e., epirubicin + oxaliplatin + fluorouracil or capecitabine [EOF or EOX])? Yes No 36. Has the member received margin-negative (R0) resection? Yes No 37. What is the member s Eastern Cooperative Oncology Group (ECOG) Performance Status (PS)? ECOG PS 0 ECOG PS 2 ECOG PS 3 ECOG PS 4 Unknown Other 38. What is the member s Karnofsky Performance Status (PS)? % Section C: Gastric Cancer 39. For which of the following clinical settings is oxaliplatin being requested? Primary chemotherapy for unresectable disease Postoperative chemotherapy Preoperative chemotherapy Palliative therapy Preoperative chemoradiation 40. Is oxaliplatin being requested to treat unresectable locoregional disease? Yes No 41. What is the prescribed regimen? Oxaliplatin + fluorouracil Epirubicin + oxaliplatin + fluorouracil (i.e., modified ECF [EOF]) Oxaliplatin + capecitabine Epirubicin + oxaliplatin + capecitabine (i.e., modified ECF [EOX]) Docetaxel + oxaliplatin + fluorouracil (i.e., modified DCF) Docetaxel + oxaliplatin + capecitabine (i.e., modified DCF) 42. Does the member meet BOTH of the following criteria? Indicate all that apply or mark "." Member has resectable locoregional disease (T2 or above) Member is medically fit for surgery 43. Does the member have locoregional disease? Yes No 44. Has the member received margin-negative (R0) resection? Yes No 45. Has the member received preoperative chemotherapy or chemoradiation? Yes No

4 46. Has the member received modified ECF regimen (i.e., epirubicin + oxaliplatin + fluorouracil or capecitabine) as preoperative chemotherapy? Yes No 47. What is the stage of the disease? T2 or above Any T, N+ 48. Has the member undergone primary D2 lymph node dissection? Yes No 49. Which of the following is applicable to the member? Persistent unresectable locally advanced, locally recurrent or metastatic disease Unresectable T4b tumors T4b squamous cell carcinoma with invasion of the trachea, great vessels, or heart T1b, N+ disease T2,T3, or T4a disease 50. What is the surgery status of the member? Member is medically unfit for surgery Member has declined surgery 51. What is the member s Eastern Cooperative Oncology Group (ECOG) Performance Status (PS)? ECOG PS 0 ECOG PS 2 ECOG PS 3 ECOG PS 4 Unknown 52. What is the member s Karnofsky Performance Status (PS)? % Section D: Hepatobiliary Cancer 53. For which of the following clinical settings is oxaliplatin being requested? As primary chemotherapy for unresectable extrahepatic cholangiocarcinoma As primary chemotherapy for metastatic extrahepatic cholangiocarcinoma As adjuvant chemotherapy for resected extrahepatic cholangiocarcinoma As primary chemotherapy for unresectable gallbladder cancer As primary chemotherapy for metastatic gallbladder cancer As primary chemotherapy for unresectable intrahepatic cholangiocarcinoma As primary chemotherapy for metastatic intrahepatic cholangiocarcinoma As adjuvant chemotherapy for resected intrahepatic cholangiocarcinoma 54. Does the member have positive regional lymph nodes? Yes No 55. What is the prescribed regimen? Oxaliplatin + fluorouracil Oxaliplatin + capecitabine Oxaliplatin + gemcitabine Section E: Neuroendocrine Tumors - Carcinoid Tumors 56. Does the member have carcinoid tumors? Yes No 57. What is the prescribed regimen? Capecitabine + oxaliplatin (CapeOx) 58. For which of the following clinical settings is oxaliplatin being requested? Metastatic progressive disease Clinically significant locoregional unresectable disease Section F: Non-Hodgkin's Lymphoma 59. What is the prescribed regimen? Gemcitabine + oxaliplatin ± rituximab (GemOx±R) Oxaliplatin + fludarabine + cytarabine + rituximab (OFAR) Oxaliplatin as a single agent 60. What is the diagnosis? Adult T-cell leukemia/lymphoma AIDS-related B-Cell Lymphoma Diffuse large B-cell lymphoma AIDS-related B-Cell Lymphoma Primary effusion lymphoma

5 AIDS-related B-Cell Lymphoma Lymphoma associated with Castleman's disease Diffuse large B-cell lymphoma Follicular lymphoma Gastric malt lymphoma Mantle cell lymphoma Mycosis fungoides (MF) /Sézary syndrome (SS) Non-gastric malt lymphoma Peripheral T-cell lymphoma Primary cutaneous B-cell lymphoma Primary cutaneous CD30+ T-cell lymphoproliferative disorders Splenic marginal zone lymphoma 61. How is oxaliplatin being requested? to be used after non-response to first-line therapy for acute T-cell leukemia or T-cell lymphoma to be used as a second-line therapy for relapsed disease to be used as a second-line therapy for recurrent disease to be used as a second-line therapy for progressive disease to be used as a second-line therapy for refractory disease to be used as subsequent therapy for refractory or progressive disease Non-Gastric MALT Lymphoma 62. Does the member have stage I-II disease? Yes No Peripheral T-Cell Lymphoma 63. Is oxaliplatin being requested to be used a second-line therapy for ANY of the following? Relapsed or refractory angioimmunoblastic T-cell lymphoma Peripheral T-cell lymphoma not otherwise specified Anaplastic large cell lymphoma Enteropathy-associated T-cell lymphoma Not used as a second line therapy 64. Is the member a candidate for transplant? Yes No Primary Cutaneous B-Cell Lymphoma 65. Is oxaliplatin being requested to be used a second-line therapy for ANY of the following? Relapsed or refractory generalized cutaneous disease Not used as a second line therapy Relapsed generalized extracutaneous disease 66. Which of the following lymphomas does the member have? Primary cutaneous marginal zone lymphoma Primary cutaneous diffuse large B-cell lymphoma, leg type Primary cutaneous follicle center lymphoma Primary Cutaneous CD30+ T-Cell Lymphoproliferative Disorders 67. Is oxaliplatin being requested to be used a second-line therapy for ANY of the following? Primary cutaneous anaplastic large cell lymphoma with multifocal lesions Cutaneous anaplastic large cell lymphoma with regional nodes Not used as a second line therapy 68. Does the member have systemic disease? Yes No Non-Hodgkin s Lymphoma Mycosis Fungoides (MF)/Sézary Syndrome (SS) 69. Does the member have a diagnosis of mycosis fungoides (MF) or Sézary syndrome (SS)?

6 70. Does the member have ANY of the following? Stage IA-IIA mycosis fungoides Stage IV non-sézary or visceral disease Stage IIB mycosis fungoides 71. Is histologic evidence of folliculotropic or large cell transformation present? Yes No 72. Does the member have generalized extent tumor, transformed, and/or folliculotropic disease? Yes No 73. Is skin-directed therapy planned for the member? Yes No Non-Hodgkin s Lymphoma CLL/SLL 74. Does the member have a diagnosis of chronic lymphocytic leukemia or small lymphocytic lymphoma (CLL/SLL)? Yes No 75. Does the member have any of the following? del(17p) Short response (less than 24 months) to first-line therapy Section G: Occult Primary 76. What is the pathologic diagnosis? Adenocarcinoma Carcinoma not otherwise specified (NOS) Squamous cell carcinoma 77. What is the member s Eastern Cooperative Oncology Group (ECOG) Performance Status (PS)? ECOG PS 0 ECOG PS 2 ECOG PS 3 ECOG PS 4 Unknown 78. What is the prescribed regimen? Oxaliplatin + capecitabine (CapeOx) Fluorouracil, leucovorin, and oxaliplatin (FOLFOX) Adenocarcinoma or Carcinoma NOS 79. For which of the following clinical settings will oxaliplatin be used? Lung nodules Unresectable liver disease Breast marker-negative pleural effusion Peritoneal mass with non-ovarian histology Resectable liver disease Disseminated metastases Chemoradiation for a localized disease with inguinal nodal involvement Squamous Cell Carcinoma 80. For which of the following clinical settings will oxaliplatin be used? Chemoradiation for a localized disease with axillary or inguinal nodal involvement Multiple lung nodules Pleural effusion Disseminated metastases Section H: Epithelial Ovarian Cancer/Fallopian Tube Cancer/Primary Peritoneal Cancer 81. For which of the following clinical settings will oxaliplatin be used? Persistent disease Recurrence 82. Will oxaliplatin be used for immediate treatment of biochemical relapse? Yes No 83. Is oxaliplatin prescribed as a single-agent therapy? Yes No Section I: Pancreatic Adenocarcinoma 84. For which of the following clinical settings will oxaliplatin be used? Locally advanced unresectable disease Progressive disease Metastatic disease 85. What is the member s Eastern Cooperative Oncology Group (ECOG) Performance Status (PS)? ECOG PS 0 ECOG PS 2 ECOG PS 3 ECOG PS 4 Unknown

7 86. Will oxaliplatin be used as a component of FOLFIRINOX (fluorouracil, leucovorin, irinotecan, and oxaliplatin) regimen? Yes No 87. Has the member received prior gemcitabine-based chemotherapy? Yes No 88. How will oxaliplatin be used? In combination with fluorouracil and leucovorin In combination with capecitabine Section J: Testicular Cancer 89. Is oxaliplatin being used after second-line or high-dose chemotherapy regimens? Yes No 90. What is the intent of the chemotherapy? Adjuvant Curative Neoadjuvant Palliative 91. How will oxaliplatin be used? In combination with gemcitabine In combination with gemcitabine and paclitaxel 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) 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. Eloxatin (oxaliplatin) Medical CareFirst MD 7/2015 CUT9692-1E (7/15) For Maryland Only