2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist?

Transcription

1 Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Colony Stimulating Factors (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health ew Jersey at When conditions are met, we will authorize the coverage of Colony Stimulating Factors (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Zarxio (filgrastim-sndz) ivestym (filgrastim-aafi) eupogen (filgrastim) eulasta (pegfilgrastim) eulasta Onpro (pegfilgrastim) Granix (tbo-filgrastim) Fulphila (pegfilgrastim-jmdb) Leukine (sargramostim) Other, specify drug Quantity Frequency Strength Route of administration Expected length of therapy Patient information Patient name: Patient ID: Patient Group o.: Patient DOB: Patient phone: Prescribing physician Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: Circle the appropriate answer for each question. Question Circle es or o 1. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? [If yes, skip to question 41.] 2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist? [If yes, skip to question 4.] Reference umber: C4510-A / Effective Date: 12/01/2018 1

2 Circle es or o 3. Is therapy prescribed by, or in consultation with, an infectious disease specialist, hematologist or Human Immunodeficiency Virus (HIV) specialist for a member with neutropenia related to Human Immunodeficiency Virus (HIV) or drug therapy? 4. Is therapy being requested for PROPHLAXIS of chemotherapy-induced febrile neutropenia in a member receiving chemotherapy for a O-myeloid cancer (i.e., solid tumor, lymphoma)? [If no, skip to question 10.] 5. Is the request for primary prophylaxis of chemotherapy-induced febrile neutropenia (member has not previously experienced neutropenia from this chemotherapy regimen)? If yes, please document number of planned chemotherapy cycles: [If no, skip to question 7.] 6. Does the member meet any of the following conditions? A) Chemotherapy regimen has greater than 20% risk of febrile neutropenia OR B) Chemotherapy regimen is given after bone marrow transplant; OR C) Chemotherapy regimen has % risk of febrile neutropenia and the member has A of the following risk factors for febrile neutropenia: age greater than 65 years, prior chemotherapy or radiation therapy, persistent neutropenia, bone marrow involvement by tumor, recent surgery and/or open wounds, renal dysfunction (creatinine clearance below 50 ml/min) or liver dysfunction (bilirubin above 2.0). [If yes, skip to question 9.] If yes, document which condition applies and chemotherapy regimen being used: 7. Is the request for secondary prophylaxis of chemotherapy-induced neutropenia in a member who previously experienced febrile neutropenia from the same chemotherapy regimen? If yes, please document number of planned chemotherapy cycles: 8. Would reducing or delaying the chemotherapy dose compromise treatment outcome? Reference umber: C4510-A / Effective Date: 12/01/2018 2

3 Circle es or o 9. Does the member meet all of the following with the requested medication? A) The requested medication will not be used concomitantly with radiation therapy AD chemotherapy, B) The requested medication will be given at the appropriate time after chemotherapy OR radiation, C) The requested medication will not be used in combination with other myeloid growth factors (MGF), D) The member does not have any contraindications or hypersensitivity to the requested medication, and E) Medical records, including labs and weight or body surface area (BSA), to support diagnosis and dosing is submitted with request [If yes, skip to question 12.] 10.Is the request for the treatment of febrile neutropenia in a member who did not receive prophylaxis with colony stimulating factors (CSFs)? [If no, skip to question 15.] 11.Does the member have risk factors for poor outcomes resulting from febrile neutropenia [for example: age greater than 65 years, sepsis, severe neutropenia absolute neutrophil count (AC) less than 100/mcL, current infection, hospitalization at onset of fever, or a prior episode of febrile neutropenia]? If yes, list which risk factor(s) apply: 12.Is this request for Zarxio or ivestym? [If yes, skip to question 14.] 13.Has the member had a trial and failure or intolerable side effects with Zarxio and ivestym? 14.Is the requested dose within FDA approved recommendations? [o further questions.] 15.Is the request for the treatment of severe chronic congenital neutropenia, congenital neutropenia, cyclic neutropenia, or idiopathic neutropenia? Reference umber: C4510-A / Effective Date: 12/01/2018 3

4 [If no, skip to question 17.] Circle es or o 16.Does the member have OE of the following? A) Evidence of inadequate bone marrow reserve (for example: recurrent fevers, splenomegaly, mucosal ulcers, abdominal pain), B) High risk for developing serious bacterial infection (for example: primarily severe neutropenia, indwelling venous catheters, prior serious infections), or C) Current bacterial infection If yes, list which apply: 17.Is the request for the treatment of acute radiation exposure in a member who received myelosuppressive doses of radiation at a dose of 2 gray (Gy) or greater? [If yes, then no further questions.] 18.Is the request for the treatment of neutropenia related to Human Immunodeficiency Virus (HIV) or drug therapy induced (ganciclovir or zidovudine)? 19.Is the request for a member with acute myeloid leukemia (AML) who is receiving induction or consolidation chemotherapy? 20.Is the request for mobilization of hematopoietic progenitor cells in a member before autologous stem cell transplant OR for mobilization of hematopoietic progenitor cells in a donor before allogeneic stem cell transplant? 21.Is the request for r treatment of neutropenia in a member with myelodysplastic syndrome (MDS)? 22.Is the request for treatment of aplastic anemia in a member with an absolute neutrophil count (AC) less than 500? Please document date lab drawn and AC: [If yes, then skip to question 30.] Reference umber: C4510-A / Effective Date: 12/01/2018 4

5 Circle es or o 23.Is therapy being requested for a member with acute myeloid leukemia (AML)? [If no, skip to question 25.] 24.Is the member at least 55 years old? 25.Is therapy being requested for a member with bone marrow transplant failure or engraftment delay? 26.Is therapy being requested for myeloid reconstitution after allogeneic bone marrow transplant? 27.Is therapy being requested for myeloid reconstitution after autologous bone marrow transplantation in a member with Hodgkin s disease, non-hodgkin s lymphoma, or acute lymphocytic leukemia? 28.Is therapy being requested for a member before and after receiving an autologous peripheral blood stem cell transplantation? 29. Was the member acutely exposed to myelosuppressive doses of radiation? [If yes, skip to question 35.] 30.Is this request for Zarxio or ivestym? [If yes, skip to question 32.] 31.Has the member had a trial and failure or intolerable side effects with Zarxio and ivestym? 32.Is the requested dose within FDA approved recommendations? Reference umber: C4510-A / Effective Date: 12/01/2018 5

6 [o further questions.] Circle es or o 33.Is this request for Leukine? 34. Will Leukine be administered at the FDA-approved dose of 250 mcg/m2 per day? Please provide body surface area: [o further questions.] 35.Is this request for Leukine? 36.Will Leukine therapy be administered once daily as a subcutaneous injection? 37.Is the request for an adult or pediatric member weighing more than 40 kg? [If no, then skip to question 39.] 38.Will Leukine be administered at the FDA-approved dose of 7 mcg/kg? [o further questions.] 39.Is the request for a pediatric member weighing 15 kg to 40 kg? 40.Will Leukine be administered at the FDA-approved dose of 10 mcg/kg? [o further questions.] 41.Is the request for the prophylaxis of chemotherapy-induced neutropenia? If yes, please document number of planned chemotherapy cycles: [If no, skip to question 43.] 42.Has a recent absolute neutrophil count (AC) demonstrated a response to therapy? Reference umber: C4510-A / Effective Date: 12/01/2018 6

7 Circle es or o Please document date lab drawn and AC value: [o further questions.] 43.Has a recent absolute neutrophil count (AC), complete blood count (CBC), and/or platelet counts been provided? Please document date lab drawn and results: Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date Reference umber: C4510-A / Effective Date: 12/01/2018 7