Revised Pre-Authorization Form for Cancer Clinical Trials

Connecticut State Seal STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN He - 79 June 17, 2010 TO: All Health Insurers and Health Care Centers Authorized To Conduct Business In Connecticut RE: Revised Pre-Authorization Form for Cancer Clinical Trials This is a reminder to all health insurers and health care centers operating in Connecticut that pursuant to sections 38a-504f and 38a-542f of the Connecticut General Statutes, and section 38a-504a-3 of the Regulations of the Connecticut State Agencies, all requests for coverage of routine patient care costs for individuals enrolled in Phase I, II and III cancer clinical trials must be pre-authorized through a submission of a completed, standardized form that all providers, hospitals and institutions shall submit when seeking to enroll an insured person in the cancer clinical trial. The Connecticut Insurance Department ("Department") wants to make sure that the form is properly required and used to enable proper identification of cancer clinical trial participants and proper data collection related to benefits provided under the cancer clinical trial mandates. Working with representatives of the Connecticut Association of Health Plans, medical directors and counsel of licensed health care centers, the Attorney General's Office and clinical trial staff of the Neag Comprehensive Cancer Center of the University of Connecticut, the Department undertook a review of the cancer clinical trial pre-authorization form to update it. As a result of that review, the form has been revised and a copy of the revised form is attached for your information. A copy of the form is also available on the Department's website under "Forms". Please contact the Insurance Department Life & Health Division at cid.lh@ct.govwith any questions. Insurance Commissionner's signature Insurance Commissioner www.ct.gov/cid P.O. Box 816 • Hartford. CT06142-0816 An Equal Opportunity Employer ------------- ------------------------- -------------------------- ---------------------- ------------------------- -------------------------- ------------------------- ----------------------- ------------------------ ----------------------- Request For Authorization for Coverage of Routine Patient Care Costs Associated with Cancer Clinical Trials Section I Date: Member name: Member ID #: Member Date of Birth: Health Insurer: Treating Physician: _ Contact Person for Additional Information Regarding Member's Treatment: Name: Address: Phone number: Fax number: E-mail address: Service requested is: _Outpatient _Inpatient _Office Setting If outpatient or inpatient is checked: Facility name & address: _ Please Note: Pursuant to Connecticut General Statutes Sections 38a-504a et seq. (individual coverage) or 38a-542a et seq. (group coverage), you may be asked to provide additional information about the cancer clinical trial or the member's diagnosis and condition prior to the authorization of this request. CT Insurance Dept - Revised June 2010 ------------ ------- Member name: Member ID#: Section II Diagnosis code:-----­ Stage _ Clinical trial phase: I II III Clinical trial sponsor: _ Please identify the funding source for the trial? (federal government, private entity, charitable organization - please provide specific entity name) _ Clinical Trial has been reviewed and approved by: (must check one per Conn. Gen. Stat. Sec. 38a-504b or 38a-542) National Institute of Health National Cancer Institute _Federal Food and Drug Administration _Federal Dept. of Defense _Federal Dept. of Veterans Affairs Check one: __Single center study __Multiple center study List name(s) and addressees) of center(s): Information regarding the proposed trial: (if additional space is needed for any of the following questions, please attach separate sheet) 1. Please state the anticipated therapeutic effect _ 2. How does the protocol differ from the standard treatment for this diagnosis? 3. Please provide a list of tests, procedures, drugs, equipment and other services to be covered by the trial. 4. Please attach copies of the study calendar and schema page from the clinical trial proposal. CT Insurance Dept - Revised June 20 I0