Prior Authorization Request Form: Aranesp And Procrit - Elderplan

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F
OR CVS/Caremark INTERNAL USE ONLY – Date and Time Received Completed form
from Doctor
CVS/Caremark/ ELDERPLAN
Prior Authorization Request for
Aranesp and Procrit
Fax Completed Form to: 855-633-7673 or Call 866-490-2102 for phone requests
A separate request must be completed for each drug for each patient.
Approvals will be for three (3) months only. Prior authorization will be required, with
**Please note:
updated clinical information (lab values), after a three (3) month period.
Patient Information
Physician Information
Patient Name
Name:
Member ID#
Group#
Carrier
Office Phone:
Gender:
Date of Birth:
Secure Office Fax Number:
M  F 
Office Contact Name:
NPI #
Drug Name :
Dose:
Directions:
Quantity:
Initial
Continuing
Has Dose
Therapy?
Y
N
Therapy?
Y
N
Been Titrated?
Y
N
Indications
Lab Values
Please Check Below:
All Patients
______ anemia associated with end stage renal disease
(ESRD) GFR<15, dialysis
Hb ____________
Date __________
_______ anemia associated with chronic renal failure (CRF
11 g/dl
with GFR< 60
(Hemoglobin
or less recommended for all
indications EXCEPT anemia due to chemotherapy)
10 g/dl
(Hemoglobin less than
recommended for anemia
______ anemia associated with the use of chemotherapy in
due to chemotherapy)
the treatment of cancer (Hb <10 recommended)
______ anemia associated with zidovudine (AZT) treatment
Hct ___________
Date __________
in HIV infected patients
______ anemia in patients scheduled to undergo elective,
CKD Patients Only
non- cardiac, nonvascular surgery to reduce the
need for allogeneic blood transfusions
BUN ___________
Date __________
______ Myelodysplastic Syndrome
Serum
Creatinine __________
Date __________
GFR __________
Date __________
**Supporting Clinical Statement (such as applicable protocols or guidelines followed, contraindications,
drug allergies, dialysis, or any other additional clinical information to support medication request):
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