Prior Authorization Form Erythropoiesis Stimulating Agents
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1Today’s date _____________________
Date medication needed ___________
Prior Authorization Form
Erythropoiesis-Stimulating Agents
ONLY COMPLETED REQUESTS WILL BE REVIEWED
Aranesp (Darbepoetin Alfa)
Epogen (Epoetin Alfa)
Procrit (Epoetin Alfa)
Check one:
New start
Continued treatment
Patient information (please print)
Physician information (please print)
Patient Name _____________________________________
Prescribing Physician _______________________________
Address _________________________________________
Office Address ____________________________________
City, State, ZIP Code________________________________
City, State, ZIP Code_______________________________
Patient Telephone # ________________________________
Office Contact _____________________________________
Patient ID # _______________________________________
Office Telephone # _________________________________
Date of Birth ____________ Height _______ Weight _______
Fax # ____________________ NPI ____________________
Upon approval, delivery is available by completing the section below.
N/A – No delivery requested, authorization only - physician will use office supply
Delivery requested (indicate where medication should be delivered: Physician’s office Patient’s home)
**A copy of the prescription must accompany the medication request for delivery.**
1.
Physician specialty (required; specify all specialties) _____________________________________________________
2.
Diagnosis for drug requested:
Anemia (specify ICD-9 code)_____________
Other (specify ICD-9 code
3. Patient medical information:
a. Is the patient on dialysis?
Yes
No
b. Is the patient’s hemoglobin (Hb) level less than 10 g/dl (or hematocrit [HCT] less than 30%)?
Yes
No
Yes
No
c. Does the patient have anemia secondary to a regimen of myelosuppressive chemotherapy?
4. Myelodysplastic Syndrome
a. Does the patient have myelodysplasia with bone marrow blast count of less than 10 percent blasts?
Yes
No
Yes
No
b. Are the pretreatment erythropoietin levels are less than or equal to 500 IU/L?
Yes
No
c. Is the patient’s Hb less than 10 g/dL (or HCT is less than 30 percent) at initiation of therapy?
d. Is the intent of therapy to maintain an Hb/HCT level no greater than 10-12 g/dL (Hb) or 30-36 percent
Yes
No
(HCT)?
5. Perisurgical adjuvant therapy (Epoetin Alf Only [Epogen, Procrit])
a. Is the patient Hb between 10-13 g/dL (or HCT is between 30-39 percent)?
Yes
No
b. Is the patient a candidate for autologous blood transfusion?
Yes
No
Yes
No
c. The individual is expected to lose more than two units of blood?
d. Has the patient been evaluated to ensure that anemia is due to chronic disease?
Yes
No
6. Prescription information:
Quantity _______________ Refill x _______month(s)
Instructions (include dose) _______________________________ every _________ day(s)/ week(s)/ month(s)
Physician’s signature__________________________________________________
Fax completed form to 215-761-9165. Your office will receive a response by fax within two business days.
4/2013 INJ-08.00.75f
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company,
and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
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