Colony Stimulating Factor Prior Authorization Form

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COLONY STIMULATING FACTOR PRIOR AUTHORIZATION FORM
This Coverage Policy applies to Coventry Managed Medicaid Health Plans.
Coverage Criteria: Neupogen, Neulasta and Leukine are approved in accordance with the FDA-labeled indications.
All requests are reviewed on the basis of medical necessity.
***Neulasta, is generally covered under the Medical Benefit. However, Neulasta is designated as an
injectable that can be self-administered by Coventry Health Care, Inc. and some health plans have moved
coverage to the Pharmacy benefit, for members with commercial benefits. Thereby requiring
documentation of medical necessity for office use, i.e. member can not self inject. ***
PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE – PHARMACEUTICAL SERVICES
Return Form to: PA FAX 855-799-2549
PHONE: (877) 215-4100
Requesting Physician:
Office Contact:
Call Center ID:
Tax ID Number:
Plan ID:
Benefit:
Office Fax Number:
Phone Number:
Office Address:
MEMBER INFORMATION
Patient Name:
DOB:
Member ID#:
Date of Request:
MEDICAL INFORMATION
Please submit additional clinical notes and documentation as appropriate for your request.
What is the indication for the requested medication?
o Bone marrow transplant
o Chronic neutropenia; Etiology: ____________________________________________________________
o Peripheral blood progenitor cell collection
o Myelosuppressive cancer chemotherapy
Type of cancer: ___________________________________________________________________________
Chemotherapy regimen (include dates, frequency, and # cycles): ___________________________________
________________________________________________________________________________________
Risk factors for increased risk of chemotherapy-induced infectious complications:
1.
o Pre-existing neutropenia due to disease
o Extensive prior chemotherapy
o Previous irradiation to the pelvis or other areas containing large amounts of bone marrow
o History of recurrent febrile neutropenia with prior chemotherapy of similar or lesser dose intensity
o Conditions potentially enhancing the risk of serious infection; Specify:_______________________
o Age ¾ 65 years old
o Other: _________________________________________________________________________
o Neutropenia due to Hepatitis C therapy
o Neutropenia due to HIV; List current HIV medications: _________________________________________
o Other; Specify: __________________________________________________________________________
What is the requested medication?
2.
o Neupogen (filgrastim)
o Leukine (sargramostim)
o Neulasta (Pegfilgrastim)
3.
What is the requested: DOSE:
FREQUENCY:
DURATION:
WHERE is the medication being administered? o Home (self-administered) o Office administration
4.
Please provide the most recent laboratory evidence:
5.
WBC with differential:
________________________ Date of test: __________________
Absolute neutrophil count (ANC): ________________________ Date of test: __________________
ADDITIONAL COMMENTS:
PHYSICIAN’S SIGNATURE:
PHYSICIAN’S SPECIALTY:
CHCH 2013-0021-001 (11/13)
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