Aranesp (Darbepoetin Alfa) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Aranesp (darbepoetin alfa)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: _______________________________
Prescribing Physician: _________________________
Patient ID #:
_______________________________
Physician Address:
_________________________
Patient DOB: _______________________________
Physician Phone #:
_________________________
Date of Rx:
_______________________________
Physician Fax #:
_________________________
Patient Phone #: ____________________________
Physician Specialty:
_________________________
Patient Email Address: ________________________
Physician DEA:
_________________________
Physician NPI #:
_________________________
Physician Email Address: ______________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
Aranesp (darbepoetin alfa)
__________________
______________________
Specify: _________________
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
□
□
Yes
No
Individual is continuing therapy with the requested drug If yes:
□
□
Yes
No
The hemoglobin (Hgb) level exceeds 11.0 g/dL
Please specify current Hgb: ________g/dL
□
□
Yes
No
Iron stores (including transferrin saturation and ferritin) are adequately maintained and
monitored periodically during therapy
□
□
Yes
No
Individual has Hgb levels less than 10.0 g/dL, prior to initiation of therapy
□
□
Yes
No
Individual’s iron status, prior to initiation of therapy, includes transferrin saturation or ferritin or bone
marrow evaluation If yes:
□
□
Transferrin saturation is at least 20%
Yes
No
□
□
Yes
No
Ferritin is at least 80ng/mL
□
□
Bone marrow demonstrates adequate iron stores
Yes
No
□
□
The individual has hypertension If yes:
Yes
No
□
□
Yes
No
Blood pressure will be adequately controlled before initiation of therapy and closely
monitored and controlled during therapy
□
□
Individual has anemia associated with chronic kidney disease If yes:
Yes
No
□
□
Yes
No
Individual is on dialysis
□
□
If yes , I ndividual is using the requested medication to achieve and
Yes
No
maintain hemoglobin levels within the range of 10 to 11 g/dL
□
□
If no, Individual is using the requested medication to achieve and
Yes
No
maintain hemoglobin levels of 10.0g/dL
□
□
Individual has a diagnosis of cancer If yes:
Yes
No
□
□
Treatment of anemia in the cancer individual is due to the effect of concomitantly
Yes
No
administered chemotherapy known to produce anemia If yes:
□
□
Chemotherapy is planned for a minimum of 2 months
Yes
No
□
□
Individual has a diagnosis of non-myeloid cancer and anticipated
Yes
No
outcome is not cure
□
□
Individual has Myelodysplastic syndrome with endogenous erythropoietin level < 500 mUnits/mL
Yes
No
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CONTINUED ON PAGE 2
Aranesp NTL PAB Fax Form 07.09.13.doc
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