Enalidomide - Pre-Authorization Form

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PRIOR-AUTHORIZATION OF LENALIDOMIDE (REVLIMID™)
Maryland Pharmacy Program
Tel#: 410-767-1455 or 1-800-492-5231 Option 3-Fax form to: 410-333-5398
(Incomplete forms will be returned)
Patient Information
Patient location: ____ Home; ____ Hospital___ Clinic___Office
Age: _______ Date of Birth:______/______/______
Patient Name:__________________________________
MA ID#:______________________________________
Address: ________________________________________
Tel.#:(____________) ______________-_________
________________________________________________
Has Patient received Red Blood Cell (RBC) transfusions in the past?  Yes
 No
Is Patient currently receiving RBC transfusions?
 Yes
 No
Is Prescriber registered in the Rev Assist program?
 Yes
 No
List prior antimyeloma or MDS therapies:___________________________________________________________________
_____________________________________________________________________________________________________
Monthly lab tests are required for monitoring adverse effects and drug toxicity. Please provide most recent test results for:
Platelet Count: ___________________________/mcL Absolute Neutrophil Count (ANC) ___________________/mcL
Test date: _______/________/_______ Date of last Office Visit:_______/________/_______Fax medical history summary
when requesting initiation of therapy and for continuation of therapy, fax monthly platelet and ANC count to 410-333-5398.
Prescriber Information
Is Revlimid™ prescribed as part of a clinical study?  Yes
 No
Specify sponsoring organization/drug manufacturer_________________________________________________________
Specify purpose of study: _____________________________________________________________________________
Note: Off-label use or use of Revlimid™ at dosages or for indications other than recommended by FDA must be medically
necessary and supported by the official compendia as mandated by CMS for use in determination of drug coverage for
Medicaid Programs.
I certify that Patient is not enrolled in any study involving the requested drug. I will be supervising the patient’s treatment
accordingly. Supporting medical documentation is kept on file in the patient’s medical record.
___________________________, M.D. Prescriber’s Name: ________________________________ Date: ____________
(Prescriber’s signature)
Tel# (_________) – __________- _________Fax# (________) - _________ - __________
License #: _________________NPI #:____________ Specialty : ____________________________________________
Address: ____________________________________________________________________________________________
Prescription Information
Drug/Strength/dosage prescribed: _________________________________________________________________________
List diagnosis for which the drug was prescribed:
 Treatment of transfusion-dependent anemia due to Low-or Intermediate-1 risk myelodysplastic syndromes (MDS)
associated with a deletion 5q cytogenetic abnormality with or without additional cytogenetic abnormalities.
 MDS not related to 5 q deletion abnormality
 Previously treated multiple myeloma
 Multiple myeloma in combination with dexamethasone as first-line therapy
 Chronic lymphoid leukemia
 Other: ___________________________________________________________________________________________
FOR INTERNAL USE
Approved: 
Denied: 
Date: _________________Reviewer’s Initials_____________
Reason for denial: _______________________________________________________________________________________
c:\.MSWord\RevlimidPAformJune09

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