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Drug Authorization Request Form
Epoetin alfa (Procrit®)
Member Information
Last Name_____________________________________ First Name ________________________ Sex _________
DOB ______________________ Card # ____________________________ Height __________ Weight _________
Address ________________________________________City _______________ ST ________ Zip_____________
Contact Name _________________________ Home phone (____)____________ Work phone (____)____________
Provider Information
Provider Name __________________________________ Phone (____)_______________ Fax (____)___________
Address ________________________________________ City _______________ ST ________ Zip ____________
DEA# _________________________________________Specialty_______________________________________
Medication ___ Procrit (epoetin alfa)___________
Dispense Quantity__________ Refill X ______________month (s)
Sig:
 Treatment of anemia of chronic kidney disease
 Adults
 _________ units/kg/week (range: 80-300 units/kg/week) _________ (IV or subcutaneous) in ___________
divided doses per week (range: 2-3)
Wt:__________ kg
Dose/week: __________units
 10,000 units subcutaneous once weekly
 Other: _____________________________________________________________________________________
 Pediatrics (≥3 months or ≥1 month if on dialysis)
 _________ units/kg/week (range: 50-250 units/kg once to three times weekly) _________ (IV or subcutaneous) in
___________ divided doses per week (range: 1-3)
Wt:__________ kg
Dose/week: __________units
 Other: _____________________________________________________________________________________
 Treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies
 Adults
 150 units/kg subcutaneous three times weekly
Wt:__________ kg
Dose: _____________units
 40,000 units subcutaneous once weekly
 Other: _____________________________________________________________________________________
 Pediatrics (≥6 months)
 _________ units/kg/week (range: 25-300 units/kg three to seven times weekly) _________ (IV or subcutaneous) in
___________ divided doses per week (range: 3-7)
Wt:__________ kg
Dose/week: _________units
 Other: _____________________________________________________________________________________
 Other: __________________________________________________________________________________________
 Treatment of anemia associated with zidovudine therapy in patients with HIV
 Adults
 100 units/kg ____________ (IV or subcutaneous) three times weekly for 8 weeks
Wt:__________ kg
Dose: _____________units
 40,000 units subcutaneous once weekly for 8 weeks
 Other: _____________________________________________________________________________
 Pediatrics (≥8 months)
 _________ units/kg/week (range: 50-400 units/kg two to three times weekly) _________ (IV or subcutaneous) in
___________ divided doses per week (range: 2-3)
Wt:__________ kg
Dose/week: _________units
 Other: _____________________________________________________________________________________
 For the reduction of allogeneic blood transfusions in surgery patients
 300 units/kg/day subcutaneous for 10 days prior to surgery, on day of surgery , and for 4 days after surgery
Wt:__________ kg
Dose/day: _____________units
 600 units/kg subcutaneous once weekly x4 doses on days 21, 14, and 7 days prior to surgery and on day of surgery
Wt:__________ kg
Dose/week: _____________units
Medication ___ Procrit (epoetin alfa)___________
Dispense Quantity__________ Refill X ______________month (s)
Sig:
 Treatment of anemia in patients with non-myeloid malignancies who are NOT receiving chemotherapy
 100 units/kg subcutaneous three times weekly
Wt:__________ kg
Dose: __________units
 ____________units/kg (range: 150-300 units/kg) subcutaneous three times weekly
Wt:_______ kg
Dose: __________units
 Other: __________________________________________________________________________________________
 Treatment of anemia in patients with myelodysplastic syndrome
 150 units/kg/day subcutaneous
Wt:__________ kg
Dose/day: __________units
 40,000 units subcutaneous ____________ (once or twice) weekly
 Other: __________________________________________________________________________________________
 For the prevention of anemia associated with frequent blood donations
 600 units/kg IV twice weekly for 3 weeks starting _____________ days (range: 25-35 days) prior to surgery
Wt:__________ kg
Dose: __________units
 Other: __________________________________________________________________________________________
 Treatment of ribavirin-induced anemia in patients with hepatitis C
 40,000 units subcutaneous once weekly
 Other: __________________________________________________________________________________________
 Treatment of anemia associated with rheumatoid arthritis and rheumatic disease
 ____________units/kg/week (range: 80-720 units/kg/week) __________ (IV or subcutaneous) in ____________ divided
doses per week (range: 2-3)
Wt:__________ kg
Dose/week: _____________units
 Other: __________________________________________________________________________________________
 Supplies package (no charge): syringes (27g, ½”, 1cc, ndc 08290-3096) qty ____ or 25g, 5/8”, 1cc, ndc 08290-3096-26 qty _____ ,
sharps disposal unit (regular or large), alcohol wipes (100 per box). PRN refills.
DIAGNOSIS:
ICD9 CODE:
Physician’s Signature______________________________________________________Date_________________________
Drug/Clinical Information
1.
Does the patient have anemia associated with chronic kidney disease, non-myeloid cancer,
myelodysplastic syndrome, or rheumatoid arthritis/rheumatic disease?
Yes
2.
Please proceed to Question 3
Please proceed to Question 7
No
Coverage not approved
Please proceed to Question 5
No
Coverage not approved
Please proceed to Question 6
No
Coverage not approved
Have other causes of anemia such as iron deficiency, folic acid and vitamin B 12 deficiencies, occult blood
loss, infectious/malignant/inflammatory processes, hematologic disease, aluminum intoxication,
hemolysis, and osteitis fibrosa cystica been excluded or appropriately treated?
Yes
7.
No
Is the ferritin concentration ≥100 ng/mL?
Yes
6.
Please proceed to Question 6
Is the transferrin saturation ≥20%?
Yes
5.
Please proceed to Question 2
Is the patient receiving epoetin alfa for the reduction of allogeneic blood transfusions or for the prevention
of anemia associated with frequent blood donations in patients scheduled for surgery?
Yes
4.
No
Does the patient have anemia associated with zidovudine treatment in patients with HIV or ribavirin
treatment in patients with hepatitis C?
Yes
3.
Please proceed to Question 4
Please proceed to Question 7
No
Coverage not approved
 For patients with chronic kidney disease:
a.
Has the creatinine clearance been <60 mL/min for at least 3 months?
Yes
Please proceed to Question b
No
Coverage not approved
No
Coverage not approved
No
Please proceed to Question d
b. Is the hemoglobin <11 g/dL?
Yes
c.
Please proceed to Question c
Is the patient at least 3 months of age?
Yes
Please proceed to Question e
d. Is the patient at least 1 month of age AND receiving dialysis?
Yes
e.
Please proceed to Question e
No
Coverage not approved
A nephrologist recommended epoetin alfa for this patient. Submit letter of recommendation.
Yes
Approved for one year pending receipt of current monthly lab values
No
Coverage not approved
 For patients with anemia associated with nonmyeloid cancer and who are receiving chemotherapy:
f.
Is the hemoglobin <10 g/dL?
Yes
g.
Please proceed to Question i
No
Please proceed to Question g
No
Coverage not approved
Is the hemoglobin >10 g/dL but <12 g/dL?
Yes
Please proceed to Question h
h. Does the patient have symptoms of anemia affecting functional capacity or quality of life such as
extreme fatigue or malaise, cold intolerance, tachycardia, congestive heart failure, shortness of
breath, severe angina, severe hypotension, or severe pulmonary distress?
Yes
i.
Please proceed to Question k
No
Please proceed to Question j
Please proceed to Question k
No
Coverage not approved
Does the patient have an erythropoietin concentration ≤200 mUnits/mL?
Yes
l.
Coverage not approved
Does the patient have documented anemia after chemotherapy treatment within the past year?
Yes
k.
No
Has the patient received chemotherapy for at least 2 months?
Yes
j.
Please proceed to Question i
Please proceed to Question l
No
Coverage not approved
No
Coverage not approved
Is the patient at least 6 months of age?
Yes
Please proceed to Question m
m. An oncologist recommended epoetin alfa for this patient. Submit letter of recommendation.
Yes
Coverage approved for 1 year pending receipt of current monthly lab values
No
Coverage not approved
 For patients with anemia associated with zidovudine therapy in patients with HIV:
n. Is the hemoglobin <13 g/dL for men or <12 g/dL for women?
Yes
o.
Please proceed to Question o
No
Coverage not approved
Does the patient have an erythropoietin concentration ≤500 mUnits/mL?
Yes
Please proceed to Question p
No
Coverage not approved
p. Is the patient taking zidovudine doses <4200 mg/week?
Yes
Please proceed to Question q
No
Coverage not approved
q. Does the patient have symptoms of anemia affecting functional capacity or quality of life such as
extreme fatigue or malaise, cold intolerance, tachycardia, congestive heart failure, shortness of
breath, severe angina, severe hypotension, or severe pulmonary distress?
Yes
r.
No
Coverage not approved
No
Coverage not approved
Is the patient at least 8 months of age?
Yes
s.
Please proceed to Question r
Please proceed to Question s
An infectious disease specialist recommended epoetin alfa for this patient. Submit letter of
recommendation.
Yes
Coverage approved for 1 year pending receipt of current monthly lab values
No
Coverage not approved
 For the preoperative use of epoetin alfa for the reduction of allogeneic blood transfusions:
t.
Is the hemoglobin 10-13 g/dL?
Yes
Please proceed to Question u
No
u. Does the patient have an anemia of chronic disease?
Coverage not approved
Yes
v.
Please proceed to Question v
No
Coverage not approved
Is the patient scheduled for major, elective, noncardiac, nonvascular surgery and expected to
require >2 units of blood?
Yes
Please proceed to Question w
No
Coverage not approved
w. Is the patient unable or unwilling to participate in an autologous blood donation program?
Yes
x.
Please proceed to Question x
No
Coverage not approved
A surgeon recommended epoetin alfa for this patient. Submit letter of recommendation.
Yes
Coverage approved for 1 year pending receipt of current monthly lab values
No
Coverage not approved
 For patients with anemia associated with nonmyeloid cancer NOT receiving chemotherapy:
y.
Is the hemoglobin <11 g/dL?
Yes
z.
Please proceed to Question z
No
Coverage not approved
Does the patient have an erythropoietin concentration ≤200 mUnits/mL?
Yes
Please proceed to Question aa
No
Coverage not approved
aa. Does the patient have symptoms of anemia affecting functional capacity or quality of life such as
extreme fatigue or malaise, cold intolerance, tachycardia, congestive heart failure, shortness of
breath, severe angina, severe hypotension, or severe pulmonary distress?
Yes
Please proceed to Question bb
No
Coverage not approved
bb. An oncologist recommended epoetin alfa for this patient. Submit letter of recommendation.
Yes
Coverage approved for 1 year pending receipt of current monthly lab values
No
Coverage not approved
 For patients with anemia associated with myelodysplastic syndrome:
cc. Is the hemoglobin <10 g/dL?
Yes
Please proceed to Question dd
No
Coverage not approved
dd. Does the patient have an erythropoietin concentration <500 mUnits/mL?
Yes
Please proceed to Question ee
No
Coverage not approved
ee. Does the patient have symptoms of anemia affecting functional capacity or quality of life such as
extreme fatigue or malaise, cold intolerance, tachycardia, congestive heart failure, shortness of
breath, severe angina, severe hypotension, or severe pulmonary distress?
Yes
Please proceed to Question ff
No
Coverage not approved
ff. An oncologist recommended epoetin alfa for this patient. Submit letter of recommendation.
Yes
Coverage approved for 1 year pending receipt of current monthly lab values
No
Coverage not approved
 For the preoperative use of epoetin alfa for the prevention of anemia associated with frequent blood
donations:
gg. Is the patient scheduled for elective surgery and expected to donate ≥4 units of blood?
Yes
Please proceed to Question hh
No
Coverage not approved
hh. A surgeon recommended epoetin alfa for this patient. Submit letter of recommendation.
Yes
Coverage approved for 1 year pending receipt of current monthly lab values
No
Coverage not approved
 For patients with anemia associated with ribavirin therapy in patients with hepatitis C:
ii. Is the hemoglobin ≤12 g/dL?
Yes
jj.
Please proceed to Question jj
No
Coverage not approved
Does the patient have symptoms of anemia affecting functional capacity or quality of life such as
extreme fatigue or malaise, cold intolerance, tachycardia, congestive heart failure, shortness of
breath, severe angina, severe hypotension, or severe pulmonary distress?
Yes
Please proceed to Question kk
No
Coverage not approved
kk. An internist recommended epoetin alfa for this patient. Submit letter of recommendation.
Yes
Coverage approved for 1 year pending receipt of current monthly lab values
No
Coverage not approved
 For patients with anemia associated with rheumatoid arthritis or rheumatic disease:
ll.
Is the hemoglobin ≤11 g/dL?
Yes
mm.
No
Coverage not approved
Does the patient have symptoms of anemia affecting functional capacity or quality of life
such as extreme fatigue or malaise, cold intolerance, tachycardia, congestive heart failure,
shortness of breath, severe angina, severe hypotension, or severe pulmonary distress?
Yes
nn.
Please proceed to Question mm
Please proceed to Question nn
No
Coverage not approved
A rheumatologist recommended epoetin alfa for this patient. Submit letter of
recommendation.
Yes
Coverage approved for 1 year pending receipt of current monthly lab values
No
Coverage not approved
Please provide chart notes to document and support statements made above