Endocrine Therapy Prior Authorization Form — Breast Cancer Treatment and Risk Reduction
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A provider-facing authorization form governing prior authorization requests for select endocrine therapies (anastrozole, exemestane, letrozole, raloxifene, Soltamox, tamoxifen) for Blue Cross Blue Shield - Maine members. It applies to requests for these drugs and documents required clinical information to determine coverage.
No material clinical or coverage changes in this revision.
Coverage Determination Criteria
Clinical data required for coverage determination
Coverage assessment is based on the following provider-confirmed clinical criteria collected on the form.
Collected via questions 1 and 2 on the form
Agent-specific requirements
- Raloxifene requirement: If Raloxifene is requested, patient must be post-menopausal
Question 3
- Soltamox requirement: If Soltamox (tamoxifen oral solution) is requested, patient must be unable to swallow or have difficulty swallowing tamoxifen tablets
Question 4
The form implies that certain agent-specific conditions must be met for coverage. Specifically, requests for Raloxifene must document that the patient is post-menopausal, and requests for Soltamox must document that the patient is unable to swallow or has difficulty swallowing tamoxifen tablets. If these agent-specific conditions are not affirmed on the form, the request may be considered outside the intended indications captured by this authorization form.
Completion of the clinical questions is required to determine coverage. Absence of answers to the eligibility items — including whether the medication is for a woman aged >35 at increased risk, for current/prior breast cancer or DCIS, or the agent-specific menopause/swallowing items — may render the request not medically necessary or incomplete and subject the request to denial or additional information requests.
Initial Authorization Requirements
Initial authorization requirements
Initial authorization relies on completion of the form questions confirming indication and relevant patient factors.
Questions 1 and 2 on the form
Provider Submission & Documentation Requirements
Prior Authorization Required
Prior authorization submission — Complete the prior authorization request form with all clinical answers and the physician signature. Fax the fully completed form (do not include a cover sheet) to the payer contact for Maine: 844-474-3351 (fax) or 844-474-6221 (alternative). Ensure provider name, address, phone, requested drug selection, and signature/date are present.
- Include selected drug: Anastrozole, Exemestane, Letrozole, Raloxifene, Soltamox, or Tamoxifen
- Fax transmission: do not include a cover sheet
Required Documentation
Required documentation — The completed form must document the clinical indication(s) and eligibility criteria. Answer all checklist questions and provide supporting details in the clinical rationale area: diagnoses, relevant risk factors (e.g., atypical ductal/lobular hyperplasia, lobular carcinoma in situ, BRCA1/2, history of chest radiation, family history), prior history of breast cancer or DCIS, menopausal status when requesting Raloxifene, and swallowing ability if requesting Soltamox. Include any other diagnoses, symptoms, or pertinent clinical information.
- Document patient age (>35) when applicable
- List specific risk factors (atypia, LCIS, BRCA, chest radiation, family history)
- If Raloxifene: state patient is post‑menopausal
- If Soltamox: document inability or difficulty swallowing tamoxifen tablets
- Include physician signature and date
Step Therapy
Step therapy — There are no step therapy sequencing or drug‑step requirements specified on this form. Providers should still verify member plan rules for any additional plan‑level step edits before prescribing.
- No drug‑step or sequencing required on this prior authorization form
Key Definitions
Background
This prior authorization form applies to endocrine agents used for breast cancer treatment or risk reduction, including Anastrozole, Exemestane, Letrozole, Raloxifene, Soltamox, and Tamoxifen. The form gathers whether the medication is being prescribed for a woman aged >35 at increased risk (for example, with prior atypia or LCIS, BRCA1/2, prior chest radiation, or family history) or for a patient with current or prior breast cancer/DCIS, and it includes specific items about post-menopausal status for raloxifene and swallowing ability for tamoxifen/Soltamox.
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