Medication Prior Authorization Form Lupron Eligard (leuprolide acetate) 7.5mg Eligard (leuprolide acetate) 22.5mg Eligard (leuprolide acetate) 30mg Eligard (leuprolide acetate)45mg Firmagon (degarelix) Lupaneta Pack (leuprolide acetate and norethindrone) Leuprolide acetate (immediate release) Lupron Depot (one month) (leuprolide acetate) 3.75mg Lupron Depot (one month) (leuprolide acetate) 7.5mg Lupron Depot (three month) (leuprolide acetate) 11.25mg and 22.5mg Lupron Depot (four month) (leuprolide acetate) 30mg Lupron Depot (six month) (leuprolide acetate) 45mg

Lupron Depot Ped (leuprolide acetate) 7.5mg Lupron Depot Ped (leuprolide acetate) 11.25mg Lupron Depot Ped (leuprolide acetate) 15mg Lupron Depot Ped (three month) (leuprolide acetate) 11.25mg and 30mg Supprelin LA (histrelin acetate) Synarel Nasal Spray (nafarelin acetate) Trelstar (triptorelin pamoate) 22.5mg Trelstar Depot (triptorelin pamoate) 3.75mg Trelstar LA (triptorelin pamoate) 11.25mg Vantas Implant (histrelin acetate) Zoladex (one month) (goserelin acetate) Zoladex (three month) (goserelin acetate)

Section I—Member Information Name (Last, First, Middle Initial)

WEA Trust Subscriber Number Diagnosis

Date of Birth

Medication Prior Authorization Form Lupron Page 2

1. MEDICATION

□ Eligard (leuprolide acetate) □ Firmagon (degarelix acetate) □ Lupaneta Pack (leuprolide acetate and norethindrone) □ Lupron (leuprolide) □ Lupron Depot (one month) (leuprolide acetate) □ Lupron Depot (three month) (leuprolide acetate) □ Lupron Depot (four month) (leuprolide acetate) □ Lupron Depot (six month) (leuprolide acetate) □ Lupron Depot Ped (leuprolide acetate) □ Lupron Depot Ped (three month) (leuprolide acetate) □ Supprelin LA (histrelin) □ Synarel Nasal Spray (nafarelin) □ Trelstar (triptorelin pamoate) □ Trelstar Depot (triptorelin pamoate) □ Trelstar LA (triptorelin pamoate) □ Vantas Implant (histrelin acetate) □ Zoladex (one month) (goserelin acetate) □ Zoladex (three months) (goserelin acetate)

2. STRENGTH

□ 7.5mg □ 80mg □ 3.75mg □ 5mg/mL □ 3.75mg □ 11.25mg □ 30mg □ 45mg □ 7.5mg □ 11.25mg □ 50mg □ 2mg/mL □ 22.5mg □ 3.75mg □ 11.25mg □ 50mg □ 3.6mg □ 10.8mg

□ 22.5mg □ 120mg □ 11.25mg

□ 30mg □ 45mg

□ 7.5mg □ 22.5mg □ 11.25mg □ 30mg

□ 15mg

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3. APPROVAL CRITERIA: CHECK ALL BOXES THAT APPLY NOTE: Any areas not filled out are considered not applicable to your patient and MAY AFFECT THE OUTCOME of this request. Oncology Uses

□ Yes □ No

Does the patient have hormone receptor positive breast cancer? If yes:

□ Yes □ Yes □ Yes □Yes □ No

□ Yes □ No

□ No □ No □ No

Is the patient premenopausal? Is the patient perimenopausal? Is the patient male?

Does the patient have ovarian cancer (including fallopian tube cancer and primary peritoneal cancer)? If yes:

□ Yes

□ No

Is the medication being used as hormonal therapy for clinical relapse in individuals with stage II-IV granulosa cell tumors?

□ Yes

□ No

Is the medication being used as hormonal therapy for treatment of epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer as a single agent for any of the following? Please indicate: □ Progressive, stable or persistent disease on primary chemotherapy □ Relapse after complete remission following primary chemotherapy □ Stage II-IV disease showing partial response to primary treatment □ Low grade or focal recurrences after a disease free interval of greater than six months

Does the patient have prostate cancer? If yes:

□ Yes

□ No

Is the disease clinically localized (clinically localized prostate cancer: cancer presumed to be confined within the prostate based on pre-treatment findings such as physical exam, imaging, and biopsy findings) with intermediate (T2b to T2c cancer, Gleason score of 7, or prostate specific antigen [PSA] value of 10-20 ng/ml) or higher risk of recurrence as neoadjuvant therapy with radiation therapy or cryosurgery?

□ Yes

□ No

Is the request drug being used following radical prostatectomy as adjuvant therapy when lymph node metastases are present?

□ Yes

□ No

Is the disease locally advanced (locally advanced disease [prostate cancer]: cancer that has spread from where it started to nearby tissue or lymph nodes)?

□ Yes

□ No

Is the disease other advanced (advanced prostate cancer: disease that has spread beyond the prostate to surrounding tissues or distant organs), recurrent, or metastatic (metastatic: the spread of cancer from one part of the body to another; a metastatic tumor contains cells that are like those in the original [primary] tumor and have spread)?

Endocrine Uses

□

Yes

□ No

Is the patient a child known to have central precocious puberty (defined as the beginning of secondary sexual characteristics before age eight in girls and nine in boys)?

Gynecology Uses

□ Yes □ No □ Yes □ No

Is the medication being used to induce amenorrhea in women in certain populations, including menstruating women diagnosed with severe thrombocytopenia or aplastic anemia? Does the patient have endometriosis? If yes:

□ Yes □ No □Yes □ No

Is the medication being used as initial treatment?

Is the medication being used as retreatment?

Medication Prior Authorization Form Lupron Page 4

□ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No

Does the patient have dysfunctional uterine bleeding? Does the patient have endometrial thinning prior to endometrial ablation for dysfunctional uterine bleeding? Is the medication being used as preoperative treatment as adjunct to surgical treatment of uterine fibroids ([leiomyoma uteri] may be used to reduce size of fibroids to allow for a vaginal procedure)? Is the medication being used prior to surgical treatment (myomectomy or hysterectomy) in individuals with documented anemia?

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Section II—Physician Information Physician Name

National Provider Identification (NPI) Number

Clinic Name

Address (Street, City, State, Zip Code)

Physician Telephone Number

Physician Fax Number

Physician Signature

Date

Section III—For WEA Trust Use Only Plan:

Copay Tiers:

Date of Receipt:

Remarks:

   

Approve Deny More information is needed Incomplete form Submission and review of this form does not guarantee approval of this request. Unless approved, payment of the brand-name medication will be limited to the amount the Trust would have paid for the generic equivalent. Insureds and providers will be informed of the decision in writing within approximately 30 days.

Fax to: Pharmacy Services (608) 276-9119 Mail to: WEA Trust Pharmacy Services Prior Authorization P.O. Box 7338 Madison, WI 53707-7338