3. Does the patient meet ALL of the following requirements? Y N

Transcription

1 Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA Procrit - Retacrit (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 Florida at When conditions are met, we will authorize the coverage of Procrit - Retacrit (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Procrit (epoetin alfa) Retacrit (epoetin alfa-epbx) Other, specify drug Quantity Frequency Strength Route of administration Expected length of therapy Member information Member name: Member ID: Member Group o.: Member DOB: Member 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. 1. Does the patient have a diagnosis of anemia associated with chronic kidney disease? [If no, skip to question 5.] 2. Is the request for continuation of therapy? [If yes, skip to question 4.] 3. Does the patient meet ALL of the following requirements? - ot on dialysis or receiving home dialysis Reference umber: C5079-A / Effective Date: 03/01/2019 1

2 - Hemoglobin less than 10 g/dl - Lab data within 2 months of PA submission [o further questions.] OTE: A supplemental iron therapy recommendation may be given for all 4. Does the patient meet ALL of the following requirements? - ot on dialysis or receiving home dialysis - Hemoglobin less than 11 g/dl - Lab data within 2 months of PA submission [o further questions.] 5. Does the patient have a diagnosis of anemia associated with chemotherapy? [If no, skip to question 9.] 6. Is the request for continuation of therapy? [If yes, skip to question 8.] 7. Does the patient meet ALL of the following requirements? - o existing history of iron or folate deficiency, hemolysis, or gastrointestinal bleeding - Hemoglobin less than 10 g/dl Reference umber: C5079-A / Effective Date: 03/01/2019 2

3 - Must be on or initiating chemotherapy [o further questions.] OTE: A supplemental iron therapy recommendation may be given for all 8. Does the patient meet ALL of the following requirements? - o existing history of iron or folate deficiency, hemolysis, or gastrointestinal bleeding - Hemoglobin less than or equal to 12 g/dl or lowest level sufficient to avoid transfusion [o further questions.] OTE: A supplemental iron therapy recommendation may be given for all 9. Does the patient have a diagnosis of anemia associated with human immunodeficiency virus (HIV)? [If no, skip to question 13.] 10.Does the patient meet the following requirement? - Hemoglobin less than 13 g/dl in men and less than 12 g/dl in women Reference umber: C5079-A / Effective Date: 03/01/2019 3

4 11.Is the request for continuation of therapy? [If yes, no further questions.] OTE: A supplemental iron therapy recommendation may be given for all 12.Does the patient have any existing history of iron or folate deficiency, hemolysis, or gastrointestinal bleeding? [o further questions.] OTE: A supplemental iron therapy recommendation may be given for all 13.Does the patient have anemia associated with hepatitis C? [If no, skip to question 17.] 14.Does the patient meet ALL of the following requirements? - Hemoglobin less than or equal to 12 g/dl - Current combination therapy with Ribavirin Reference umber: C5079-A / Effective Date: 03/01/2019 4

5 15.Is the request for continuation of therapy? [If yes, no further questions.] 16.Does the patient have any existing history of iron or folate deficiency, hemolysis, or gastrointestinal bleeding? [o further questions.] 17.Is the requested drug being prescribed to reduce the need for allogenic blood transfusions in anemic patients scheduled to undergo elective, noncardiac, nonvascular surgery? 18.Is the patient unwilling to receive donated blood? 19.Does the patient have a hemoglobin level greater than 10 and less than or equal to 13 g/dl? 20.Is the patient receiving iron supplementation? OTE: A supplemental iron therapy recommendation may be given for all 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: C5079-A / Effective Date: 03/01/2019 5