Certificate of Medical Necessity

Gonadotropin Releasing Hormone Analogs and Antagonists

Leuprolide acetate (Lupron®, Lupron Depot®, Lupron Depo-Ped®, Lupron Depot 3 Month®, Lupron Depot 4 Month®, Viadur® implant, Eligard®)

Histrelin acetate (Vantas®, Supprelin®)

Goserelin acetate (Zoladex®)

Triptorelin pamoate (Trelstar Depot®, Trelstar LA®)

Degarelix (Firmagon®)

Please fax completed CMN forms and other required documentation (i.e., physician history and physical; physician progress notes; with documentation of conservative treatment including prior medications used; treatment plan including narrative).

Statewide fax number: 904-905-9849

SECTION A

Provider Information

Name

/

BCBSF Number

/

National Provider Identifier (NPI)

Street Address

/

City

/

State

/

Zip

Telephone Number

/

Fax Number

Contact Name

Member Information

Last Name / First Name
Member/Contract Number (alpha and numeric) / Date of Birth

SECTION B

Please provide HCPC code and description. HCPCS J code ______Description ______
Please provide diagnosis code and description. ICD9 code ______Description ______
Is patient picking up medication at a retail pharmacy? / Yes No N/A
Is provider buying the medication and billing BCBSF directly? / Yes No N/A
Is provider obtaining medication from Caremark for drug replacement? / Yes No N/A
Is this the initial request or continuation of therapy. If continuation, what date was therapy initiated? ______
Please provide prescribed dosage (milligrams, administration route, frequency): ______

SECTION C

Please select medication to be reviewd and complete criteria under applicable patient condition: / Check Response
Leuprolide acetate (Lupron®, Lupron Depot®, Lupron Depo-Ped®, Lupron Depot 3 Month®, Lupron Depot 4 Month®, Viadur® implant, Eligard®) / Yes No
Endometriosis / Yes No
Is this prescribed for management of endometriosis, including pain relief and endometriotic lesions, AND / Yes No
Does dosage exceed 3.75mg every 28 days? / Yes No
Uterine Leiomyomata (fibroids) / Yes No
Is this used in conjunction with iron supplement therapy (indicated for the preoperative hematologic improvement of patients with anemia caused by uterine leiomyomata (fibroids)), AND / Yes No
Does dosage exceed 3.75mg every 28 days? / Yes No
Advanced Prostate Cancer / Yes No
Is this being used for the palliative treatment of advanced prostatic cancer, especially as an alternative to orchiectomy or estrogen administration, AND / Yes No
Does dosage exceed 7.5mg every 28 days? / Yes No
Central Precocious Puberty / Yes No
Is patient up to age of 13, AND / Yes No
Did patient have onset of secondary sexual characteristics earlier than 8 years of age in females and 9 years of age in males, AND / Yes No
Was diagnosis confirmed by a pubertal response to a GnRH stimulation test, bone age advanced 1 year beyond chronological age, AND / Yes No
Height ______Weight ______/ Yes No
Sex steroid levels ______Date Drawn ______/ Yes No
Adrenal steroid level to exclude congenital adrenal hyperplasia ______/ Yes No
Beta human chorionic gonadotropin level to rule out a chorionic gonadotropin secreting tumor ______/ Yes No
Did patient have a pelvic/adrenal/testicular ultrasound to rule out a steroid secreting tumor, AND / Yes No
Computed tomography of the head to rule out intracranial tumor / Yes No
Advanced Breast Cancer / Yes No
Is this being used for the palliative treatment of advanced breast carcinoma in premenopausal and perimenopausal women / Yes No
Ovarian Cancer / Yes No
Does dosage exceed 7.5 mg every 28 days / Yes No
Histrelin acetate (Vantas®, Supprelin®), / Yes No
Central Precocious Puberty
Is patient up to age of 13, AND / Yes No
Did patient have onset of secondary sexual characteristics earlier than 8 years of age in females and 9 years of age in males, AND / Yes No
Was diagnosis confirmed by a pubertal response to a GnRH stimulation test, bone age advanced 1 year beyond chronological age, AND / Yes No
Does dosage exceed 50 mg yearly? / Yes No
Height ______Weight ______/ Yes No
Sex steroid levels ______Date Drawn ______/ Yes No
Adrenal steroid level to exclude congenital adrenal hyperplasia ______/ Yes No
Beta human chorionic gonadotropin level to rule out a chorionic gonadotropin secreting tumor ______/ Yes No
Did patient have a pelvic/adrenal/testicular ultrasound to rule out a steroid secreting tumor, AND / Yes No
Computed tomography of the head to rule out intracranial tumor / Yes No
Advanced Prostate Cancer / Yes No
Is this being used for the palliative treatment of advanced prostatic cancer, especially as an alternative to orchiectomy or estrogen administration, AND / Yes No
Does dosage exceed 50 mg yearly? / Yes No
Goserelin acetate (Zoladex®) / Yes No
Advanced Breast Cancer / Yes No
Is this being used for the palliative treatment of advanced breast carcinoma in premenopausal and perimenopausal women, AND / Yes No
Does dosage exceed 3.6 mg every 28 days? / Yes No
Endometrial Thinning / Yes No
Will this be given prior to endometrial ablation for dysfunctional uterine bleeding, AND / Yes No
Does dosage exceed 3.6 mg every 28 days? / Yes No
Endometriosis / Yes No
Is this prescribed for management of endometriosis, including pain relief and endometriotic lesions, AND / Yes No
Does dosage exceed 3.6 mg every 28 days? / Yes No
Advanced Prostate Cancer / Yes No
Is this being used for the palliative treatment of advanced prostatic cancer, especially as an alternative to orchiectomy or estrogen administration, AND / Yes No
Does dosage exceed 10.8 mg every 12 weeks? / Yes No
Stage B2 to C Prostate Cancer / Yes No
Is this for use in combination with flutamide for the management of locally confined T2b-T4 (Stage B2 to C) carcinoma of the prostate? / Yes No
Does dosage exceed 10.8 mg every 12 weeks? / Yes No
Triptorelin pamoate (Trelstar Depot®, Trelstar LA®) / Yes No
Advanced Prostate Cancer / Yes No
Is this being used for the palliative treatment of advanced prostatic cancer, especially as an alternative to orchiectomy or estrogen administration, AND / Yes No
Does dosage exceed 11.25 mg every 84 days? / Yes No
Pancreatic Carcinoma / Yes No
Does dosage exceed 3.75 mg every 28 days for females or 11.25 mg every 84 days for males? / Yes No
Endometriosis / Yes No
Does dosage exceed 3.75 mg every 28 days? / Yes No
Uterine Fibroids / Yes No
Does dosage exceed 3.75 mg every 28 days? / Yes No
Degarelix (Firmagon®) / Yes No
Advanced Prostate Cancer / Yes No
Is GnRH agonists therapy appropriate? / Yes No
Has the patient refused surgical castration? / Yes No
Does the patient have one or more of the following: / Yes No
Risk of neurological compromise because of metastases, OR / Yes No
Ureteral or bladder outlet obstruction caused by local encroachment or metastatic disease, OR / Yes No
Severe bone pain from skeletal metastases persisting on narcotic analgesia / Yes No

Comments: ______

Form completed by:

Name/Title (Printed):
Signature: / ______/ Date: