CurrentAetnaPolicy N/A

Eligard (leuprolide acetate) Medication Precertification Request Form

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This document is a precertification/authorization request form used by Aetna for Eligard (leuprolide acetate) injections and governs the information providers must submit to request initiation or continuation of therapy for covered members.

Policy Summary

PayerAetna

PolicyEligard (leuprolide acetate) Medication Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the precertification request form to Aetna via the listed phone or fax numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page

8form sections

1-866-752-7021precert phone

1-888-267-3277precert fax

Coverage Criteria for Eligard Precertification

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CurrentAetnaPolicy N/A

Eligard (leuprolide acetate) Medication Precertification Request Form

Customize your policy alerts

Sign up for all Aetna policy alerts

Know when Aetna releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAetna

PolicyEligard (leuprolide acetate) Medication Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the precertification request form to Aetna via the listed phone or fax numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page

8form sections

1-866-752-7021precert phone

1-888-267-3277precert fax

Coverage Criteria for Eligard Precertification

Clinical criteria

Clinical information required for precertification requests

ALL of the following

Initiation Requests - indication (select one)
- Gender dysphoria
- Prostate cancer
- Recurrent salivary gland tumors
Continuation Requests - documentation required
- Prostate cancer
- Clinical benefit or toxicity
  - Has the patient experienced clinical benefit while on the current regimen (e.g., serum testosterone less than 50 ng/dL)? — Yes
  - Has the patient experienced clinical benefit while on the current regimen (e.g., serum testosterone less than 50 ng/dL)? — No
  - Has the patient experienced an unacceptable toxicity while on the current regimen? — Yes
  - Has the patient experienced an unacceptable toxicity while on the current regimen? — No

Required clinical information must be completed in its entirety for all precertification requests.

Diagnosis codes

Diagnosis information required

ALL of the following

Primary ICD Code: (provide code)
Additional diagnosis codes (if applicable)
- Secondary ICD Code: (provide code)
- Other ICD Code: (provide code)

Please indicate primary ICD code and specify any other where applicable.

Relevant Codes and Clinical Targets

Administration codingCPT

Administration code(s) (CPT)

Product and diagnosis codesmixed

	Eligard (leuprolide acetate) - product, dose, frequency
	Primary ICD Code
	Secondary ICD Code
	Other ICD Code

Testosterone target — threshold

Testosterone targetSerum testosterone less than 50 ng/dL (used as example of clinical benefit for continuation requests)

Context of useApplied as evidence of clinical benefit for patients receiving therapy for prostate cancer

Assessment timingMeasured while on current regimen to determine continuation eligibility

What Providers Must Submit

Prior Authorization

Precertification submission

Complete and submit the Eligard precertification request form to Aetna using the Precertification Notification phone or fax provided.

Phone: 1-866-752-7021 (TTY: 711)
Fax: 1-888-267-3277

Documentation Required

Supplemental documentation and Medicare note

The plan may request additional information or clarification to evaluate precertification requests; for Medicare Advantage Part B submissions, use the Medicare request form.

Aetna may request supplemental documentation if needed to evaluate the request
Medicare Advantage Part B: submit using the Medicare Request Form

Request Types Defined

Initiation Requests — definition

DefinitionRequests to start Eligard therapy; clinical documentation required to show the indication (examples listed on the form: gender dysphoria, prostate cancer, recurrent salivary gland tumors)

Required documentationIndication for initiation must be specified on the precertification form and all clinical information in Section G completed

Submission triggerUsed when a patient is not currently on Eligard and provider requests approval to begin therapy

Continuation Requests — definition

DefinitionRequests to continue an ongoing course of Eligard therapy; clinical documentation required to support continued use (e.g., prostate cancer with documented clinical benefit)

Clinical benefit exampleForm specifies assessment such as serum testosterone less than 50 ng/dL to demonstrate benefit

Toxicity considerationForm asks whether the patient has experienced unacceptable toxicity on the current regimen; responses required to inform continuation decision

Policy Summary

PayerAetna

PolicyEligard (leuprolide acetate) Medication Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the precertification request form to Aetna via the listed phone or fax numbers.

SourceLink

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