Circle Yes or Y N. [Note: requests without this information will not be accepted.] [If no, then no further questions.

Transcription

1 10/01/2016 Prior Authorization Aetna Better Health of West Virginia COLO STIMULATIG FACTORS (WV88) 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 of West Virginia at When conditions are met, we will authorize the coverage of Colony Stimulating factors (WV88). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (select from list of drugs shown) eupogen (filgrastim) Zarxio (filgastrim-sndz) eulasta (pegfilgrastim) Other, please specify Quantity Frequency Strength Route of Administration Expected Length of therapy Patient Information Patient ame: Patient ID: Patient Group o.: Patient DOB: Patient Phone: Prescribing Physician Physician ame: Specialty: PI umber: Physician Fax: Physician Phone: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. 1. Is the requested dose FDA-approved for the indication being treated? Document dose in mcg/kg and patient s weight: [ote: requests without this information will not be accepted.] [If no, then no further questions. 2. Has Aetna Better Health of West Virginia authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)? [If yes, skip to question 38.]

2 3. Is therapy prescribed by (or in consultation with) a hematologist and/or oncologist? 4. Is the request for eulasta? [If no, skip to question 15.] 5. Is therapy being requested for PROPHLAXIS of chemotherapy-induced febrile neutropenia in a patient receiving chemotherapy for a O-myeloid cancer (ie, solid tumor, lymphoma)? [If no, skip to question 13.] 6. Is the request for primary prophylaxis of chemotherapyinduced febrile neutropenia (patient has not previously experienced neutropenia from this chemotherapy regimen)? [If no, skip to question 8.] 7. Does the patient meet any of the following conditions? A) Chemotherapy regimen has at least a 20% risk of febrile neutropenia OR B) Patient has risk factors for febrile neutropenia (e.g., age greater than 65 years, pre-existing neutropenia, tumor involvement in the bone marrow, infection, renal or liver impairment, other serious co-morbidities, advanced disease, or HIV) [If yes, skip to question 10.] If yes, document which condition applies and chemotherapy regimen being used: 8. Is the request for secondary prophylaxis of chemotherapyinduced neutropenia in a patient who previously experienced febrile neutropenia from the same chemotherapy regimen? 9. Would reducing or delaying the chemotherapy dose compromise treatment outcome (i.e., treating to cure the patient)?

3 10. Is the duration between chemotherapy cycles at least 14 days? 11. Will eulasta be administered at least 24 hours after, but no greater than 72 hours after, chemotherapy? 12. Will eulasta be used concurrently with radiation therapy? [If yes, then no further questions.] [If no, skip to question 37.] 13. Is therapy requested for the treatment of ACUTE chemotherapy-induced febrile neutropenia in a patient who did not receive prophylaxis with colony stimulating factors? 14. Does the patient have risk factors for poor outcomes [eg, age greater than 65 years, sepsis, severe neutropenia (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: [If yes, skip to question 37.] 15. Is therapy being requested for PROPHLAXIS of chemotherapy-induced febrile neutropenia in a patient receiving chemotherapy for a O-myeloid cancer (ie, solid tumor, lymphoma)? [If no, skip to question 22.] 16. Is the request for primary prophylaxis of chemotherapyinduced febrile neutropenia (patient has not previously experienced neutropenia from this chemotherapy regimen)? [If no, skip to question 18.]

4 17. Does the patient meet any of the following conditions? A) Chemotherapy regimen has at least a 20% risk of febrile neutropenia OR B) Patient has risk factors for febrile neutropenia (e.g., age greater than 65 years, pre-existing neutropenia, tumor involvement in the bone marrow, infection, renal or liver impairment, other serious co-morbidities, advanced disease, or HIV) [If yes, skip to question 20.] If yes, document which condition applies and chemotherapy regimen being used: 18. Is the request for secondary prophylaxis in a patient who previously experienced febrile neutropenia from the same chemotherapy regimen? Please document # of planned chemotherapy cycles: 19. Would reducing or delaying the chemotherapy dose compromise treatment outcome (i.e., treating to cure the patient)? 20. Will therapy be administered at least 24 hours after, but no greater than 72 hours after, chemotherapy? 21. Will therapy be used concurrently with radiation therapy? [If yes, then no further questions.] [If no, skip to question 36.] 22. Is the request for the treatment of Severe Chronic eutropenia (i.e., congenital, cyclic, or idiopathic neutropenia)? [If no, skip to question 24.]

5 23. Does the patient have OE of the following? A) Evidence of inadequate bone marrow reserve (e.g., recurrent fevers, splenomegaly, mucosal ulcers, abdominal pain), B) High risk for developing serious bacterial infection (e.g., primarily severe neutropenia, indwelling venous catheters, prior serious infections), or C) Current bacterial infection If yes, list which apply: [If yes, skip to question 35.] 24. Is therapy requested for the treatment of ACUTE chemotherapy-induced febrile neutropenia in a patient who did not receive prophylaxis with colony stimulating factors? [If no, skip to question 26.] 25. Does the patient have risk factors for poor outcomes [e.g., age greater than 65 years, sepsis, severe neutropenia (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: 26. Is the request for the treatment of acute radiation exposure in a patient who received myelosuppressive doses of radiation (2 gray (Gy) or greater)? 27. Is the request for treatment of HIV-induced neutropenia? [If no, skip to question 31.] 28. Does the patient have OE of the following? A) Evidence of inadequate bone marrow reserve (e.g., recurrent fevers, splenomegaly, mucosal ulcers, abdominal pain), B) High risk for developing serious bacterial infection (e.g., primarily severe neutropenia, indwelling venous catheters, prior serious infections), or C) Current bacterial infection If yes, list which apply:

6 29. Is the patient receiving antiretroviral treatment for HIV? 30. Is the patient receiving therapy with zidovudine or sulfamethoxazole/trimethoprim? ote: Patients who require pneumocystis prophylaxis should be switched to atovaquone or dapsone (unless contraindicated). [If yes, then no further questions.] [If no, skip to question 35.] 31. Is the request for a patient with acute myeloid leukemia (AML) who is receiving induction or consolidation chemotherapy? 32. Is therapy requested for a patient receiving an autologous stem cell transplant OR for a donor before allogenic stem cell transplant? 33. Is the request for a patient with acute lymphoid leukemia (ALL) who is receiving induction or consolidation chemotherapy? 34. Is therapy requested for any of the following non-fda approved indications? A) neutropenia in patients with myelodysplastic syndrome B) adjunctive treatment of aplastic anemia (with cyclosporine, Thymoglobulin, and/or steroids) If yes, document which indication applies: 35. Does the patient have an absolute neutrophil count (AC) less than 500? Please document date lab drawn and AC: 36. Is the request for a non-preferred drug per the state PDL?

7 37. Has the patient had a minimum 30 day trial and failure of at least OE of the preferred formulary agents? If yes, please list the name of the drug(s) and dates tried, and describe treatment failure or intolerance experienced: [o further questions.] 38. Is the request for the prophylaxis of chemotherapy-induced neutropenia? _ [If no, skip to question 40.] 39. Has a recent AC demonstrated a response to therapy? Please document date lab drawn and AC value: _ [o further questions.] 40. Has a recent AC and platelet count 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