Pharmacy Prior Authorization
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- Barnard Samson Pierce
- 5 years ago
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1 Pharmacy Prior Authorization MERC CARE (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 Mercy Care 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) eulasta Onpro (pegfilgrastim) eulasta (pegfilgrastim) eupogen (filgrastim) 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: e the appropriate answer for each question. Question 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 22.] 2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist? [If yes, skip to question 4.] 3. Is therapy prescribed by, or in consultation with, an infectious disease specialist, hematologist or HIV specialist for a member with neutropenia related to HIV or drug therapy? Reference umber: C4592-A/ Effective Date: 02/01/2018 1
2 4. Is therapy being requested for PROPHLAXIS of chemotherapy-induced febrile neutropenia in a member receiving chemotherapy for a Omyeloid cancer (ie, 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 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, tumor involvement in the bone marrow, 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? 8. Would reducing or delaying the chemotherapy dose compromise treatment outcome? 9. Does the member meet all of the following with the requested medication? A) The requested medication will not be used concomitantly Reference umber: C4592-A/ Effective Date: 02/01/2018 2
3 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), and D) The member does not have any contraindications or hypersensitivity to the requested medication [If yes, skip to question 12.] 10.Is the request for eupogen for the treatment of febrile neutropenia in a member who did not receive prophylaxis with colony stimulating factors (CSF)? [If no, skip to question 13.] 11.Does the member have risk factors for poor outcomes resulting from febrile neutropenia (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: 12.Is the requested dose within FDA approved recommendations? Please provide dose in mcg/kg and member s weight: [o further questions.] 13.Is the request for eupogen for the treatment of severe chronic neutropenia (i.e., congenital, cyclic, or idiopathic neutropenia)? [If no, skip to question 15.] 14.Does the member 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: Reference umber: C4592-A/ Effective Date: 02/01/2018 3
4 15.Is the request for eupogen for the treatment of acute radiation exposure in a member who received myelosuppressive doses of radiation (2 gray (Gy) or greater)? [If yes, then no further questions.] 16.Is the request for eupogen for the treatment of neutropenia related to HIV or drug therapy (ganciclovir or zidovudine)? 17.Is the request for eupogen for a member with acute myeloid leukemia (AML) who is receiving induction or consolidation chemotherapy? 18.Is the request for eupogen for mobilization of hematopoietic progenitor cells in a member receiving an autologous stem cell transplant OR for mobilization of hematopoietic progenitor cells in a donor before allogeneic stem cell transplant? 19.Is the request for eupogen for treatment of neutropenia in a member with myelodysplastic syndrome (MDS)? 20.Is the request for eupogen for treatment of aplastic anemia in a member with absolute neutrophil count (AC) less than 500? Please document date lab drawn and AC: 21.Is the requested dose within FDA approved recommendations? Please provide dose in mcg/kg and member s weight: [o further questions.] 22.Is the request for the prophylaxis of chemotherapy-induced neutropenia? [If no, skip to question 24.] 23.Has a recent AC demonstrated a response to therapy? Reference umber: C4592-A/ Effective Date: 02/01/2018 4
5 Please document date lab drawn and AC value: [o further questions.] 24.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 Reference umber: C4592-A/ Effective Date: 02/01/2018 5
2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist?
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
More informationCircle Yes or No Y N. (Note: requests without this information will not be accepted.) [If no, then no further questions.]
04/25/2016 Prior Authorization AETA BETTER HEALTH OF LA MEDICAID Colony Stimulating Factors (LA88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
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