REVIEW REQUEST FOR
Recombinant Erythropoietin Products (Epogen®, Procrit®,
Micera®, Aranesp® Red Blood Cell Growth Factors)
Provider Data Collection Tool Based on Clinical Guideline DRUG-05
Policy Last Review Date:
Request Date:
Initial Request
Buy and bill
11/05/2015
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Policy Effective Date:
01/01/2016
Provider Tool Effective Date:
01/01/2016
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Subsequent Request
Individual’s Name:
Date of Birth:
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Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
Diagnosis Code(s) (if known):
Ordering Provider Name & Specialty:
Individual’s Weight
(lbs) (kg)
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering Provider):
Provider ID Number (if known):
Office Address:
Contact Name and Office Phone Number:
Office Fax Number:
Place of Service:
Home
Office
Dialysis Center
Outpatient Hospital
Ambulatory Infusion
Ambulatory Infusion Center
Other:
Drug Name/HCPCS Code (if known)
Dose to be administered:
Epogen®
J0885
Q4081
Procrit®
J0885
J0886
Q4081
Aranesp®
J0881
J0882
Mircera®
J0887
J0888
Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
/
/
Duration:
Start Date For This Request:
(Weeks)
/
/
(units)
(units/kg)
(mcg)
(mcg/kg)
(other)
Please complete Section A or B immediately below prior to proceeding to the disease specific request in
Section 1 - 9 Check all of the following that apply to the individual
A.
For initial authorization only:
Individual has a hemoglobin (Hgb) level less than 10 g/dl and has been assessed within 4 weeks
Current Hgb:
Date:
/
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Individual has a hemoglobin (Hgb) level greater than 10.0 g/dl and less than or equal to 13.0 g/dl and has been assessed
within 4 weeks (if request is for number 5 outlined below)
Current Hgb:
Date:
/
/
Individual’s iron status been evaluated. If checked, please check all of the following that apply:
Transferrin saturation at least 20%
Serum ferritin level is at least 80ng/ml
Date of last Iron test:
Evidence of bone marrow demonstrates adequate iron stores
Individual’s endogenous erythropoietin level less than 500 mU/ml (ONLY NEED TO COMPLETE IF REQUEST IS FOR NUMBER
3 or 4 OUTLINED BELOW)
Individual is diagnosied with hypertension and it has been controlled before initiating therapy
Individual’s hypertention will be closely monitored and controlled during therapy
B. For Re-authorization only:
Individual does NOT have uncontrolled hypertension?
Individual responded to previous treatment with Epogen®, Procrit®, Aranesp® or Mircera®
Individual has a hemoglobin (Hgb) level less than or equal to 11.0 g/dl and has been assessed within 4 weeks
Current Hgb:
Date:
/
/
Epogen®/Procrit®, Aranesp®, Mircera®
(1) Anemia of Chronic Kidney Disease (CKD)
For anemia of chronic kidney disease
Individual is on dialysis
Treatment goal is to achieve and maintain Hemoglobin levels within the ranage of 10.0 to 11.0 g/dl
Individual is NOT on dialysis
Treatment goal is to achieve and maintain a Hemoglobin level of 10.0 g/dl
Other
(2) Anemia in Individuals on Chemotherapy
Individual has anemia and is on chemotherapy known to produce for example (myelosuppressive)
Chemotherapy planned for a minimum of 2 months
Individual has a diagnosis of non-myeloid cancer
The anticipated outcome not a cure
Other
(3) Anemia in Myelodysplastic Syndrome
For anemia in Myelodysplastic Syndrome
Other
Epogen®/Procrit®:
(4) Anemia in Zidovudine treated human immunodeficiency virus (HIV)-Infected Individuals
For anemia in Zidovudine treated human immunodeficiency virus (HIV) – infected individual
Individual’s current Zidovudine dose is less than or equal to 4200mg/week
Other
(5) Anemia in Reduction of Allogeneic Blood Transfusion in Pre-Operative Surgery Individuals
For anemia and reduction of allogeneic blood transfusion in pre-operative surgery individual
Individual is scheduled for elective, noncardiac, nonvascular surgery
Individual is at high risk for perioperative transfusions with significant anticipated blood loss
Individual is unable or unwilling to donate autologous blood
Antithrombotic prophylaxis has been considered
Other
(6) Anemia in Individuals with Hepatitis C
For anemia in individual with Hepatitis C
Individual is currently on concomitant therapy of ribavirin plus interferon alfa or peginterferon alfa
Other
(7) Chronic Inflammatory Disease
Individual has chronic inflammatory disease
Individual is currently on myelosuppresive drugs (for example, disease modifying anti-rheumatic drugs) known to
produce anemia
Other
(8) Allogeneic Bone Marrow Transplant
Individual has allogeneic bone marrow transplantation
Other
(9) Other Indication(s) not otherwise specified above: (Please submit all supporting documents including labs, progress notes,
imaging, etc., for review.)
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This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
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Name & Title of Provider or Provider Representative Completing Form
Date
& attestation (Please Print)*
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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