Medical Appropriateness Review: Summary of Criteria and Information Criteria Requested for Fusilev (levoleucovorin) Number: Drugs 122 v General Demographic Information •
Drug Information (Drug Requested, JCode, Dose, Frequency, Anticipated Duration of Therapy, Diagnosis, ICD-­‐9). •
Prescribing Physician Information (Name, Address, Phone/Fax Number, NPI, Health Plan ID Number, Specialty). •
Member Demographics (Name, ID Number, DOB, Age, Gender, Height, Weight). •
Date of Request & Expected Date of Service. •
Rendering Provider Information, if different than Prescribing Physician (Name, Address, Phone/Fax Number, TIN). v Clinical Criteria: Methotrexate Toxicity •
Is racemic (d,l) leucovorin calcium available from any manufacturer? •
What is the patient’s primary indication? •
What is the patient’s full regimen? v Clinical Criteria: Colorectal cancer •
Is racemic (d,l) leucovorin calcium available from any manufacturer? •
Is the patient’s disease metastatic? •
What is the patient’s full regimen? v Renewal Request •
Has the patient experienced improvement in symptoms or stabilization of disease? •
Has the patient tolerated the treatment with minimal/no side effects? For a complete description of the medical necessity criteria for this drug therapy, read Horizon Blue Cross Blue Shield of New Jersey’s medical policies by logging into NaviNet.net. Disclaimer: This summary sheet is for informational purposes only. Do not fax this to ICORE or Horizon BCBSNJ to convey a request for medical necessity and appropriateness review. To initiate such a request, please visit icorehealthcare.com and click Providers and Physicians or call ICORE at 1-­‐800-­‐424-­‐4508. This document contains prescription brand name drugs that are registered marks or trademarks of pharmaceutical manufacturers not affiliated with either Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association. This summary sheet is accurate as of 1/2015 Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. © 2013 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.