CurrentAnthemPolicy N/A

Breast Cancer Copay Waiver Form

A payer form used by providers to request a copay waiver for select breast cancer prevention or treatment medications (anastrozole, exemestane, letrozole, raloxifene, tamoxifen/Soltamox) documenting patient and provider information and clinical indications to support the waiver request. Includes fax instructions and state-specific fax numbers.

Policy Summary

PayerAnthem

PolicyBreast Cancer Copay Waiver Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionProviders must complete patient and provider information, indicate the drug requested, answer the clinical screening questions, document diagnoses/symptoms, sign and date the form, and fax the completed form (do not include a cover sheet) to the payer using the state- and exchange-specific fax numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this is an administrative copay waiver request form; no policy changes listed.

6Medications listed on form

MultipleState/exchange fax numbers provided

Policy summary

This is an administrative copay waiver request form for selected agents used in breast cancer prevention or treatment. It is intended for providers to document clinical and administrative information to support a waiver determination for the following medications: Anastrozole, Exemestane, Letrozole, Raloxifene, and Tamoxifen/Soltamox.

Providers must complete patient and provider identifying information, answer the clinical screening questions, include physician signature and date, and fax the completed form to the payer using the provided state- and exchange-specific fax numbers. The form must be faxed without a cover sheet to the payer-specific numbers listed on the form.

Key Facts

PolicyBreast Cancer Copay Waiver Form

PayerAnthem

StatusCURRENT

Medications listed on formAnastrozole; Exemestane; Letrozole; Raloxifene; Soltamox (tamoxifen); Tamoxifen

State/exchange fax numbers providedMultiple state- and exchange-specific fax numbers listed (e.g., Colorado, California, New Hampshire, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New York, Ohio, Wisconsin, Virginia, Plan Specific, COVA)

Scope summaryA payer form used by providers to request a copay waiver for select breast cancer prevention or treatment medications (anastrozole, exemestane, letrozole, raloxifene, tamoxifen/Soltamox) documenting patient and provider information and clinical indications to support the waiver request. Includes fax instructions and state-specific fax numbers.

Form questions and clinical indications

Form Questions / Clinical Indications

Provider must complete the form and indicate answers to the following clinical questions to support a breast cancer copay waiver request:

ALL of the following

Patient and provider information: Patient and provider identifying information completed (Patient Name, ID #, DOB; Provider Name, Address, Phone).
Drug selection: Drug requested indicated by selecting one or more: Anastrozole, Exemestane, Letrozole, Raloxifene, Soltamox (tamoxifen), Tamoxifen.
Risk/Prevention indication
- Women >35 at increased risk: Medication prescribed to a woman aged > 35 years who is at increased risk for breast cancer, including women with previous benign breast lesions on biopsy (such as atypical ductal or lobular hyperplasia and lobular carcinoma in situ), and/or other risk factors (e.g. BRCA 1/2, history of chest radiation therapy, family history of breast cancer).
- Current or previous breast cancer or DCIS: Medication prescribed to a woman who has a current or previous diagnosis of breast cancer or ductal carcinoma in situ (DCIS).
Drug-specific additional questions
- Raloxifene post-menopausal: If the requested medication is Raloxifene, is the patient post-menopausal?
- Tamoxifen swallowing difficulty: If the requested medication is Soltamox (tamoxifen), is the patient unable to swallow or have difficulty swallowing tamoxifen tablets?
Provider documentation: Provider documents diagnoses, symptoms, and other information important to the review in the provided space.
Signature: Physician signature and date are provided on the form.

Required provider actions

Documentation Required

Complete form with clinical answers and signature

Providers must complete patient and provider identifying information, indicate the drug requested, answer the clinical screening questions (risk factors, prior/current breast cancer or DCIS, drug-specific questions), document diagnoses/symptoms, and provide physician signature and date on the form before faxing.

Patient identifiers: Patient Name, ID #, DOB
Provider identifiers: Provider Name, Address, Phone
Select drug requested from list: Anastrozole, Exemestane, Letrozole, Raloxifene, Soltamox (tamoxifen), Tamoxifen
Answer clinical screening items: risk/prevention indication, current or prior breast cancer or DCIS
Answer drug-specific questions: post-menopausal status for Raloxifene; swallowing ability for Soltamox (tamoxifen)
Document diagnoses, symptoms, and other relevant clinical information
Physician signature and date

Billing Rule

Fax submission requirements and state-specific numbers

Completed forms must be faxed without a cover sheet to the payer using the state- and exchange-specific fax numbers shown on the form. Multiple phone numbers are provided for some states/plans; use the numbers displayed on the form for the appropriate state or exchange.

Do not include a cover sheet when faxing the completed form
Multiple phone numbers may be listed per state/plan — use the number shown on the form for the applicable state or exchange

Scope, faxing and applicability

This form covers a copay waiver request for select breast cancer prevention and treatment medications (Anastrozole, Exemestane, Letrozole, Raloxifene, Tamoxifen/Soltamox).

It documents patient and provider information, the drug requested, and a set of clinical indication questions including risk/prevention criteria (e.g., women aged > 35 at increased risk, prior benign breast lesions, BRCA 1/2, prior chest radiation, family history) and current or prior diagnosis of breast cancer or DCIS. Drug-specific questions (e.g., post-menopausal status for Raloxifene; swallowing difficulty for Soltamox/tamoxifen) are included, and space is provided to document diagnoses, symptoms, and other pertinent information. A physician signature and date are required.

The form includes fax submission instructions and multiple state- and exchange-specific fax numbers; completed forms must be faxed to the listed numbers and must not include a cover sheet.

Compact Key Values

Medications listed on form6

Fax numbersState/exchange-specific; multiple per state/plan

Intended usersProviders submitting copay waiver requests

Policy Summary

PayerAnthem

PolicyBreast Cancer Copay Waiver Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Breast Cancer Copay Waiver Form

Policy summary

Form questions and clinical indications

Required provider actions

Scope, faxing and applicability

Document changes