Temodar® (temozolomide) Injection
Medication Precertification Request
Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
Page 1 of 2
(All fields must be completed and legible for precertification review.)
Start of treatment: Start date
/
/
Continuation of therapy, Date of last treatment
Precertification Requested By:
For Medicare Advantage Part B:
FAX:
1-844-268-7263
Please indicate:
/
/
Phone:
Fax:
A. PATIENT INFORMATION
First Name:
Last Name:
Address:
City:
Home Phone:
State:
Work Phone:
Patient Current Weight:
lbs or
B. INSURANCE INFORMATION
Cell Phone:
kgs Patient Height:
Aetna Member ID #:
Group #:
Insured:
inches or
Medicaid:
Yes
Last Name:
Address:
Allergies:
Yes
No
Carrier Name:
No If yes, provide ID #:
(Check one):
City:
Fax:
Provider Email:
M.D.
State:
St Lic #:
NPI #:
ZIP:
Email:
cms
Does patient have other coverage?
If yes, provide ID#:
Insured:
Medicare:
Yes
No If yes, provide ID #:
C. PRESCRIBER INFORMATION
First Name:
Phone:
DOB:
DEA #:
Office Contact Name:
D.O.
N.P.
P.A.
ZIP:
UPIN:
Phone:
Specialty (Check one):
Oncologist
Other:
D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION
Place of Administration:
Self-administered
Physician’s Office
Outpatient Infusion Center
Phone:
Center Name:
Home Infusion Center
Phone:
Agency Name:
Administration code(s) (CPT):
Address: ____________________________________________________
E. PRODUCT INFORMATION
Request is for: Temodar® (temozolomide)
Dose:
Dispensing Provider/Pharmacy: Patient Selected choice
Physician’s Office
Retail Pharmacy
Specialty Pharmacy
Mail Order
Other:
Name:
Address: ___________________________________________________
Phone:
Fax:
TIN:
PIN:
Frequency:
F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other where applicable.
Primary ICD Code:
Secondary ICD Code:
Other:
(attach clinical rationale)
G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests.
For All Requests
Adult Intracranial and Spinal Ependymoma (Excluding Subependymoma)
Yes
No Has the patient experienced disease progression?
Yes
No Will Temodar be used as a single agent?
Adult Low-Grade Infiltrative Supratentorial Astrocytoma/Oligodendroglioma (excluding pilocytic astrocytoma)
Yes
No Will Temodar be used as a single agent for adjuvant chemotherapy, or for recurrent or progressive disease?
Adult Medulloblastoma and Supratentorial Primitive Neuroectodermal Tumors (PNET)
Yes
No Will Temodar be used as recurrence therapy as a single agent?
Yes
No Has the patient experienced disease progression?
Yes
No Has the patient received prior chemotherapy?
Anaplastic Gliomas
Yes
No Will Temodar be used as adjuvant treatment and treatment of recurrent disease?
Yes
No Will Temodar be used as a single agent or in combination with bevacizumab?
Angiosarcoma
Yes
No Will Temodar be used as single agent palliative therapy?
Central Nervous System Cancers
Please indicate which of the following the patient will be treated for?
Limited (1-3) metastatic lesions
Multiple (>3) metastatic lesions
Other: please explain: ______________________________
Yes
No Will Temodar be used as treatment for recurrent disease?
Yes
No Does the patient have recurrent stable systemic disease?
Yes
No Will Temodar be used as a single agent treatment if active against primary tumor for brain metastases?
Continued on next page
GR-69129 (12-16)
Temodar® (temozolomide) Injection
Medication Precertification Request
Page 2 of 2
(All fields must be completed and legible for precertification review.)
Patient First Name
Patient Last Name
Patient Phone
Aetna Precertification Notification
503 Sunport Lane, Orlando, FL 32809
Phone: 1-866-503-0857
FAX:
1-888-267-3277
For Medicare Advantage Part B:
FAX:
1-844-268-7263
Patient DOB
G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests.
Dermatofibrosarcoma Protuberans (DFSP)
Yes
No Does the patient have metastatic disease?
Ewing's Sarcoma Family of Tumors
Yes
No Does the patient have progressive, relapsed, or metastatic disease?
Yes
No Will Temodar be used in combination with irinotecan with or without vincristine?
Glioblastoma
Yes
No Will Temodar be used as adjuvant treatment following resection with or without carmustine polymer?
Yes
No Will Temodar be used as treatment of recurrent disease as a single agent or in combination with bevacizumab?
Lung Neuroendocrine Tumors
Yes
No Is Temodar being used as treatment for stage IIIb-IV low or intermediate-grade neuroendocrine carcinoma?
Yes
No Will Temodar be used as a single agent or in combination with capecitabine?
Melanoma
0
1
2
3
4
5
Please indicate the patients performance status:
Yes
No Will Temodar be used for metastatic or unresectable disease as second-line or subsequent therapy for disease progression?
Mycosis Fungoides (MF)/Sezary Syndrome (SS)
Yes
No Will Temodar be used as second line chemotherapy?
Neuroendocrine Tumors of the Pancreas
Yes
No Does the patient have unresectable locoregional disease or distant metastatic disease?
Yes
No Is the patient exhibiting symptoms, clinically significant tumor burden, or clinically significant progression?
Yes
No Will Temodar be used as a single agent or in combination with capecitabine?
Pheochromocytoma/Paraganglioma
Yes
No Will Temodar be used as primary treatment as a single agent for distant metastases?
Primary CNS Lymphoma
Yes
No Will Temodar be used as induction therapy in combination with high-dose methotrexate and rituximab (Rituxan)?
Yes
No Will Temodar be used for treatment as a single agent or in combination with rituximab for progressive or recurrent disease?
Retroperitoneal/intraabdominal soft tissue sarcoma
Yes
No Does the patient have unresectable or progressive disease?
Yes
No Will Temodar be used as single agent palliative chemotherapy?
Rhabdomyosarcoma
Pleomorphic rhabdomyosarcoma
Nonpleomorphic rhabdomyosarcoma
Other: ___________________
Please select the indication:
Yes
No Will Temodar be used as a single agent palliative therapy?
Yes
No Will Temodar be used in combination with vincristine and irinotecan?
Small cell lung cancer
0
1
2
3
4
5
Please indicate the patients performance status:
Yes
No Is the patient being treated for primary progressive disease or for relapse?
Yes
No Will Temodar be used as a single agent for subsequent chemotherapy?
Soft tissue sarcoma of the extremity/superficial trunk, head/neck
Yes
No Does the patient have synchronous stage IV or recurrent disease with disseminated metastases?
Solitary Fibrous Tumor/Hemangiopericytoma
Yes
No Will Temodar be used in combination with bevacizumab?
Uterine sarcoma
Yes
No Will Temodar be used as single agent therapy?
For Continuation Requests
Yes
No Does the patient have a hypersensitivity to Temodar?
Please indicate which of the following reactions the patient had:
Steven-Johnson syndrome
toxic epidermal necrolysis
anaphylaxis
infusion related adverse reactions
uticaria
other: please explain:____________________
H. ACKNOWLEDGEMENT
Request Completed By (Signature Required):
Date:
/
/
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or
deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading,
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
The plan may request additional information or clarification, if needed, to evaluate requests.
GR-69129 (12-16)