Epoetin Alfa And Darbepoetin Alfa - Medical Necessity Request Form
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2Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
– Medical Necessity Request
Epoetin Alfa and Darbepoetin Alfa
*Please complete page 1 for New/Initial Requests*
1. Does the member have Anemia? Yes or No
- If no, what is the drug being used for? _____________________________________________________
2. Have other causes of anemia been excluded (e.g. GI bleeding, iron or folate deficiency, hemolysis)? Yes or No
3. Is the member currently on iron therapy? Yes or No
4. Does the member have sickle cell disease? Yes or No
Please select the cause of anemia and answer related questions.
□ Chronic Kidney Disease/End-Stage Renal Disease
- Will the member be receiving dialysis? Yes or No If No, answer the following questions.
- Is the goal of using this medication to reduce the risk of alloimmunization and/or other red blood cell transfusion-
related risks? Yes or No
- Does the member have a rate of hemoglobin decline which would indicate the likelihood of requiring a red blood cell
transfusion? Yes or No
□ HIV
- Is member currently receiving AZT (Zidovudine)? Yes or No
- If yes, please provide the dose that member is receiving __________________________________
□ Cancer/Chemotherapy
- What type of cancer does the member have? ______________________________________________________________
- What chemotherapy is the member receiving? _____________________________________________________________
- How many month of chemotherapy are planned? _________________
□ Upcoming Surgery
- Is the patient at high-risk for blood loss from surgery? Yes or No
- Would the drug reduce the need for an allogenic blood transfusion (from another person)? Yes or No
- Is the member scheduled to undergo elective, non-cardiac, non-vascular surgery? Yes or No
□ Hepatitis C
- Is the member being treated with ribavirin and interferon/PEG interferon? Yes or No
□ Rheumatoid Arthritis/Rheumatic Disease
□ Myleodysplastic syndrome
□ Bone Marrow Transplant
- Has the member had an allogenic bone marrow transplant (from another person)? Yes or No
□ Other: __________________________
Clinical Values
Contraindication Information
*Please submit laboratory documentation for
hemoglobin and hematocrit taken within the
Does the member have uncontrolled hypertension? Yes or No
past 60 days.
Has the member had pure red cell aplasia (PRCA) that begins after
Current weight: _________ lbs or kg
treatment with an erythropoeitin protein drug such as Procrit,
Epogen or Aranesp or Mircera? Yes or No
Hemoglobin: ______g/dL Date taken: _________
If female, is the member pregnant or nursing? Yes or No
Hematocrit: _________%. Date taken: ________
Transferrin Saturation: _______%
Ferritin level: _________ng/mL
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
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Rev. 03/16
HNJH Fax #: 888-567-0681
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