Fillable Pharmacy Prior Authorization Request Form Colony Stimulating Factors (Mercy Care)

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Pharmacy Prior Authorization Request Form Colony Stimulating Factors (Mercy Care)

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The Pharmacy Prior Authorization Request Form Colony Stimulating Factors (Mercy Care) form is 3 pages long and contains:

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  • 49 check-boxes
  • 61 other fields

Country of origin: US
File type: PDF

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Effective: 08/18/2020 C4592-A Page 1 of 3
Proprietary
Fax completed prior authorization request form to 800-854-7614 or submit Electronic Prior Authorization through
CoverMyMeds® or SureScripts.
All requested data must be provided. Incomplete forms or forms without the chart notes will be returned
Pharmacy Coverage Guidelines are available at
www.mercycareaz.org/providers/completecare-forproviders/pharmacy
Colony Stimulating Factors (CSF)
Pharmacy Prior Authorization Request Form
Do not copy for future use. Forms are updated frequently.
REQUIRED: Medical records, including labs and weight or body surface area (BSA), to support diagnosis are required to be submitted
Member Information
Member Name (first & last): Date of Birth: Gender:
☐ ☐ Male Female
Height:
Member ID: City: State: Weight:
Prescribing Provider Information
Provider Name (first & last): Specialty: NPI# DEA#
Office Address: City: State: Zip Code:
Office Contact: Office Phone Office Fax:
Dispensing Pharmacy Information
Pharmacy Name: Pharmacy Phone: Pharmacy Fax:
Requested Medication Information
Preferred Short Acting: Neupogen Disposable Syringe Neupogen Vial
Preferred Long Acting:
Fulphila Udenyca
Non-Preferred Short-Acting: Granix Leukine Nivestym Zarxio
Non-Preferred Long-Acting: Neulasta Neulasta Onpro
Ziextenzo
Other, please specify:
Are there any contraindications to formulary medications?
Yes No
If yes, please specify:
New
request
Continuation of
therapy request
For continuation of therapy
requests ONLY:
Response to therapy Recent ANC, CBC and/or
PLT counts
Chemotherapy induced neutropenia ONLY:
Recent ANC showing response to therapy
Directions for Use: Strength: Dosage Form:
Quantity: Day Supply: Duration of Therapy/Use:
What medication(s) has member tried and failed for this diagnosis? Please specify:
Medication request is NOT for an FDA approved, or compendia-
supported diagnosis (circle one): Yes No
Diagnosis: ICD-10 Code:
Turn-Around Time for Review
Standard – (24 hours) Urgent – waiting 24 hours for a standard decision could seriously harm life, health, or
ability to regain maximum function, you can ask for an expedited decision.
Signature:
_______________________________________________________
Clinical Information
Will requested medication be used concomitantly with radiation AND chemotherapy? Yes No
Will requested medication be administered
at appropriate time after chemotherapy OR
radiation?
Yes No Will requested medication be used in
combination with other myeloid growth factors?
Yes No
Chemotherapy-Induced Febrile Neutropenia
PRIMARY Prophylaxis
Member is receiving chemotherapy for NON-myeloid cancer AND Chemotherapy regimen is given after bone marrow transplant
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Effective: 08/18/2020 C4592-A Page 2 of 3
Proprietary
meets ONE of the following (check that apply): Chemotherapy regimen has >20% risk of febrile neutropenia
Chemotherapy regimen has 10%-20% risk of febrile neutropenia
AND ANY of the following risk factors for febrile neutropenia:
Age > 65 years Persistent neutropenia
Prior chemo OR radiation Renal dysfunction
CrCl < 50
Bone marrow involvement by
tumor
Liver dysfunction
bilirubin > 2.0
Recent surgery AND/OR open wounds
SECONDARY Prophylaxis
Did member previously experienced febrile neutropenia from same chemotherapy regimen? Yes No
TREATMENT
Has member received a Long Acting CSF
for prophylaxis?
Yes No If already received Zarxio,
Nivestym, Neupogen OR Granix,
will there be continuation with
same agent?
Yes No N/A
Prophylactic therapy with a CSF was not received AND risk factors
for poor outcome resulting from febrile neutropenia are present:
(check that apply)
Age > 65 Current infection
Sepsis Hospitalized at onset of fever
Severe neutropenia –
ANC less than 100/mcL
Prior episode of febrile
neutropenia
Severe Chronic Congenital, Cyclic OR Idiopathic Neutropenia
Member has ONE of the following: Evidence of inadequate
bone marrow reserve
High risk for developing
serious bacterial infection
Current bacterial
infection
Neutropenia related to HIV or drug therapy - Ganciclovir OR Zidovudine Induced
Was medication prescribed by OR in consultation with ID Specialist, Hematologist OR HIV specialist? Yes No
Other Indications
Neupogen – Zarxio – Nivestym are approvable for
ANY of the following indications:
AML in members receiving induction or consolidation chemotherapy
Mobilization of hematopoietic progenitor cells before autologous stem cell
transplant
Mobilization of hematopoietic progenitor cells in the donor before allogenic
stem cell transplant
Treatment of acute radiation exposure in members who receive
myelosuppressive doses of radiation at a dose of 2 gray (Gy)
MDS or aplastic anemia in a member with ANC <500
Leukine is approvable for ANY of the following
indications:
AML after induction chemotherapy for members age 55 years or older
Bone marrow transplant failure or engraftment delay
Myeloid reconstitution after autologous bone marrow transplant in members with
Hodgkin’s disease, non-Hodgkin's lymphoma, or ALL
Before AND after autologous peripheral blood stem cell transplantation
Members acutely exposed to myelosuppressive doses of radiation, administer
once daily as subcutaneous injection
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records
Page 3 of 3
Signature affirms that information given on this form is true and accurate and reflects office notes.
___________________________________________________ Prescribing Provider’s Signature: Date:
Please note: Incomplete forms or forms without the chart notes will be returned.
Medical records, including labs and weight or body surface area (BSA), to support diagnosis are required to be submitted.
Standard turnaround time is 24 hours. You can call 800-624-3879 to check the status of a request.
Effective: 08/18/2020 C4592-A
Proprietary
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Pharmacy Prior Authorization Request Form Colony Stimulating Factors (Mercy Care)

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Completed 31 July 2021

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