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.
No material clinical or coverage changes in this revision.
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
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)
Relevant Codes and Clinical Targets
| Administration code(s) (CPT) |
| Eligard (leuprolide acetate) - product, dose, frequency | |
| Primary ICD Code | |
| Secondary ICD Code | |
| Other ICD Code |
What Providers Must Submit
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
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
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