Prior Authorization Request Form - Brcavantage
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3Prior Authorization Request Form
For Breast and Ovarian Cancer Screening by Molecular Testing
Sample Collection Date Member ID Number or Subscriber Social Security Number
Date of Birth
Member Name
Member Address
Member Telephone Number
Risk Criteria Category:
1
Women with a personal history of ovarian
cancer. Date of ovarian cancer diagnosis (Month
/ Year
)
2
Women with a personal history of breast cancer
and any of the following:
Date of breast cancer diagnosis (Month
/ Year
)
1. Breast cancer is diagnosed at age 45 years or younger; or
2. Breast cancer is diagnosed at age 50 years or younger, with any of the following. The member has:
3
a. at least one close blood relative
with breast cancer at age 50 years or younger; or
3
b. at least one close blood relative
with epithelial ovarian cancer; or
5
c. bilateral breast cancer or two primaries
, with first diagnosis age 50 years or younger; or
4
d. limited family structure
or no family history available because member is adopted.
3. Breast cancer is diagnosed at any age, with any of the following:
3
a. at least two close blood relatives
on the same side of the family with breast cancer and/or epithelial ovarian
cancer at any age; or
5
3
b. the member has two breast primaries
and also has at least one close blood relative
with breast cancer
diagnosed at age 50 or younger; or
3
c. the member has two breast primaries and also has at least one close blood relative
with epithelial ovarian
cancer; or
3
d. close male blood relative
with breast cancer; or
e. if ethnicity is associated with higher mutation frequency (Ashkenazi Jewish), no additional family history is
6
required
; or
3
f.
if member has two close relatives
on the same side of the family with pancreatic adenocarcinoma at any age.
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4. Breast cancer is triple negative
and is diagnosed at age 60 years or younger
Women without a personal history of breast cancer or ovarian cancer.
3
5. Women with three or more close blood relatives
on the same side of the family with breast cancer, irrespective of
age at diagnosis; or
3
6. Women with two close blood relatives
on the same side of the family with:
1
a. epithelial ovarian cancer
; or
b. breast cancer, one of whom was diagnosed at age 50 years or younger; or
1
c. breast cancer in one relative and epithelial ovarian cancer
in another relative.
3
7. Women with at least one close blood relative
with:
a. male breast cancer; or
1
b. both breast and epithelial ovarian cancer
5
8. Women with a first-degree relative with bilateral breast cancer
.
9. Women of Ashkenazi Jewish descent with one or more 1st-degree relatives or two or more 2nd-degree relatives with
6
breast or epithelial ovarian cancer
3
10. Women with a personal history of pancreatic adenocarcinoma at any age with two close blood relatives
on the same
side of the family with breast cancer, epithelial ovarian cancer, and/or pancreatic adenocarcinoma at any age.
Women with a first (mother, sister, daughter), second (grandmother, aunt, niece), or third degree (great
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grandmother, great aunt, first cousin) blood relative with a known BRCA1 or BRCA2 mutation.
Women who do not meet any of the above criteria but are determined through both independent formal genetic
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counseling and quantitative risk assessment tool
to have at least a 10% pre-test probability of carrying a
BRCA1 or BRCA2 mutation. Note: In this category, a three-generation pedigree and quantitative risk
assessment results must be faxed directly to Aetna at: 860-975-9126. Pedigree template available upon request.
Formal Genetic Counseling (please check the box that applies)
Yes
No
Genetic Counselor Name
Location (State)
Male members with:
1. A personal history of breast cancer; or
2. A first, second, or third degree blood relative with a known BRCA1 or BRCA2 mutation where the results will
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influence clinical utility (i.e. reproductive decision making)
.
continued
GR-67606-4 (10-14)
Page 1 of 3
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