Intravenous (Iv) Iron Therapy - Medical Necessity Request Form

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Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Intravenous (IV) Iron Therapy – Medical Necessity Request
1. Can the member take oral iron instead? Yes or No
a. If yes, please call the oral iron prescription into the member’s pharmacy, then return form to HNJH.
b. If no, what is the clinical reason why the member cannot take oral iron therapy?
______________________________________________________________________________
2. What is the member’s diagnosis?
□ Anemia
□ Other: ________________________________
3. What is the anemia due to?
□ Iron Deficiency
□ Cancer/Chemotherapy
□ Other: ________________________________
4. Is the member receiving an erythropoietin (e.g., Procrit)? Yes or No
5. Does the member have Chronic Kidney Disease? Yes or No
a. Is the member undergoing hemodialysis? Yes or No
b. Is the member undergoing peritoneal dialysis? Yes or No
c. Is the member receiving an erythropoietin (e.g., Procrit)? Yes or No
6. For Ferric Gluconate Complex (Ferrlecit, Nulecit), Iron Sucrose (Venofer) and Ferumoxytol (Feraheme)
requests, does the member have evidence of iron overload? Yes or No
Lab Values – Please specify units for all values and fax a copy of the lab results.
 Serum iron level: _______________
Date Taken: _____________________
 Total Iron Binding Capacity: ___________
Date Taken: _____________________
 Serum Ferritin: ___________
Date Taken: _____________________
 Transferrin Saturation (TSAT): ___________
Date Taken: _____________________
 Hemoglobin: ___________
Date Taken: _____________________
*Please note, levels must be from within the past 60 days
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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