Today’s date _____________________
Date medication needed ___________
Prior Authorization Form
ONLY COMPLETED REQUESTS WILL BE REVIEWED
Aranesp (Darbepoetin Alfa)
Epogen (Epoetin Alfa)
Procrit (Epoetin Alfa)
Patient information (please print)
Physician information (please print)
Patient Name _____________________________________
Prescribing Physician _______________________________
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.**
Physician specialty (required; specify all specialties) _____________________________________________________
Diagnosis for drug requested:
Anemia (specify ICD-9 code)_____________
Other (specify ICD-9 code
3. Patient medical information:
a. Is the patient on dialysis?
b. Is the patient’s hemoglobin (Hb) level less than 10 g/dl (or hematocrit [HCT] less than 30%)?
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?
b. Are the pretreatment erythropoietin levels are less than or equal to 500 IU/L?
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
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)?
b. Is the patient a candidate for autologous blood transfusion?
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?
6. Prescription information:
Quantity _______________ Refill x _______month(s)
Instructions (include dose) _______________________________ every _________ day(s)/ week(s)/ month(s)
Fax completed form to 215-761-9165. Your office will receive a response by fax within two business days.
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.