angle-left Colony Stimulating Factors Request Form

Colony Stimulating Factors Precertification Request Form

Precertification/Prior Authorization may be required under certain plans. Please verify each member’s benefits.

Prescribers: The following documentation is REQUIRED for completion of review. Incomplete forms will be returned for additional information.

Electronic submission is preferred. See Providers and select Provider-Administered Drug Policies at the website on the back of the member’s ID card.

Note: Medications received through manufacturer coupons or samples are not accepted as justification of prior therapy.

PATIENT INFORMATION                                                                                     Today’s date:

Patient First Name:

Patient Last Name:

MI:

DOB (mm/dd/yyyy):

Patient Street Address:

City, State

ZIP

Patient Phone:

Member ID Number:

Group Number:

PRESCRIBER/CLINIC INFORMATION

Prescriber First Name:

Prescriber Last Name:

NPI:

Specialty:

Clinic Name:

Contact Name:

Phone:

Secure Fax:

Clinic Street Address:

City, State

ZIP

SERVICING PRESCRIBER INFORMATION

Servicing Prescriber Name:

NPI:

Prescriber Phone:

Contact Name:

Contact Phone:

Secure Fax:

Street Address:

City, State

ZIP

MEDICAL INFORMATION. PLEASE ATTACH ADDITIONAL INFORMATION AS NEEDED.

Patient Diagnosis with ICD-9 Code:

ICD-10 Code:

HCPCS Code:

Medication and Strength Requested:

Dosing Schedule:

Requested Quantity:

Requested Dosing Period Start Date:

End Date:

Place of Service:

Route of Administration:

Healthcare professional to administer?

Yes   No

Buy and Bill:

Yes   No

Is the use of the requested agent for an oncology related diagnosis? ................................................................................

Yes

No

If yes: Please refer to the provider portal on the website on the back of the member’s ID card to submit a request to the Oncology Program.

Is the patient receiving concurrent chemotherapy and radiation? .........................................................................................

Yes

No

If yes: will the requested agent be given for prophylactic use? .................................................................................

Yes

No

Please list all other medications the patient is currently taking for treatment of this diagnosis.________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Please list all reasons for selecting the requested medication, strength, dosing schedule and quantity over alternatives: (e.g. contraindications to other medications; lower dose has been tried.) _____________________________________________________

____________________________________________________________________________________________________________ ____

Please list the medications the patient has previously tried and failed for the treatment of this diagnosis:

______________________________     Date: ______________       ______________________________    Date: _____________

______________________________     Date: ______________       ______________________________    Date: _____________

______________________________     Date: ______________       ______________________________    Date: _____________              

Please select the requested medication and answer any corresponding questions where applicable:

Granix® (tbo-filgrastim)

Does the patient have a history of hypersensitivity reactions to filgrastim or peg-filgrastim?........................................

Yes

No

Please specify the dose of Granix for this patient:

5 mcg/kg/day            Other: ____________________________________________________________________________  

Please specify the patient’s current weight:______________   LBS     KGS

Please continue to the next page.

Patient First Name:

Patient Last Name:

MI:

DOB (mm/dd/yyyy):

Leukine® (sargramostim)

Does the patient have a history of hypersensitivity reactions to Leukine or yeast-derived products?...........................

Yes

No

Does the patient have excessive leukemic myeloid blasts in bone marrow or peripheral blood (10%)?.....................

Yes

No

Please specify the dose of Leukine for this patient:

250 mcg/m² daily              Other: _________________________________________________________________________

Please specify the patient’s body surface area (m²):____________

Neupogen® (filgrastim) or Zarxio® (filgrastim-sndz)

Does the patient have a history of hypersensitivity reactions to Neupogen or Zarxio?..................................................

Yes

No

Please specify the dose of Neupogen or Zarxio for this patient:

5 mcg/kg daily                   6 mcg/kg twice daily                10 mg/kg daily               Other: ________________________

Please specify the patient’s current weight:______________   LBS    KGS

Fulphila (pegfilgrastim-jmdb)

Does the patient have a history of hypersensitivity reactions to pegfilgrastim or filgrastim products? .........................

Yes

No

Please specify the dose of Fulphila for this patient:

6 mg once per chemotherapy cycle      Other: ______________________________________________________________

Nivestym (filgrastim-aafi)

Does the patient have a history of hypersensitivity reactions to pegfilgrastim or filgrastim products? ........................

Yes

No

Please specify the dose of Nivestym for this patient:

5 mcg/kg daily                   6 mcg/kg twice daily                10 mg/kg daily               Other: ________________________

Please specify the patient’s current weight:_____________      LBS     KGS

Udenyca (pegfilgrastim-CBQV)

Does the patient have a history of hypersensitivity reactions to pegfilgrastim or filgrastim products? .......................

Yes

No

Please specify the dose of Udenyca for this patient:

6 mg once per chemotherapy cycle    Other: _________________________________________________________

Neulasta® (pegilgrastim)

Does the patient have a history of hypersensitivity reactions to pegfilgrastim or filgrastim products? ........................

Yes

No

Please specify the dose of Neulasta for this patient:

6 mg once per chemotherapy cycle       Two 6 mg doses one week apart                Other: ________________________

Please select the condition for which the medication is being prescribed and answer corresponding question(s):

Leukemic relapse after allogeneic stem-cell transplantation as an alternative or adjunct to donor leukocyte infusions

Mobilization of autologous hematopoietic progenitor cells into the peripheral blood for collection by leukapheresis

Myelodysplastic syndrome

What is the patient’s ANC level? ______________ mm3

Does the patient have a history of recurrent or resistant bacterial infections? ..............................................................

Yes

No

Will the requested agent be used for the enhancement of erythropoietic activity for the treatment of refractory anemia? .............................................................................................................................................................................

Yes

No

Will the requested agent be used with erythropoietin (Procrit, Epogen)? ......................................................................

Yes

No

Is the patient’s serum erythropoietin level ≤500 mU/mL? ...............................................................................................

Yes

No

Does the patient currently have adequate iron stores? ..................................................................................................

Yes

No

Secondary prophylaxis in patients who had a neutropenic episode or dose-limiting neutropenic even from a prior chemotherapy cycle

Has the patient had prior use of colony stimulating factors (CSFs)? .............................................................................

Yes

No

Would a reduced dose or change in treatment regimen compromise disease or overall survival or treatment outcomes? .........................................................................................................................................................................

Yes

No

Primary prophylaxis for the prevention of febrile neutropenia (FN) in patients receiving a chemotherapy regimen

What is the patient’s overall risk? _________________ %

Is the patient’s chemotherapy being administered on a weekly basis? .........................................................................

Yes

No

Has the prescriber assessed the patient’s risk factors and the patient has any of the following?

               Age is greater than 65                                                         Bone marrow involvement by tumor         

               Chronic immunosuppression in the transplant setting      HIV infection

               Liver dysfunction (bilirubin greater than 2 mg/dL)             Persistent neutropenia           

               Prior chemotherapy or radiation therapy                            Poor performance status

               Recent surgery and/or open wounds                                 Renal dysfunction (creatinine clearance less than 50 mL/min)

             ☐ Other (Please specify): __________________________________________________________________________________

Please continue to the next page.

Patient First Name:

Patient Last Name:

MI:

DOB (mm/dd/yyyy):

Patient has undergone an allogeneic or autologous BMT and has a delayed or failed engraftment

Patient was acutely exposed to myelosuppressive doses of radiation to increase survival

Therapeutic use for Febrile Neutropenia (FN)

Does the patient have at least one factor for infection-related complications or poor clinical outcome? ....................

Yes

No

Old age (>65 years)                                                                       Pneumonia                               Hospitalization

Severe or anticipated prolonged neutropenia                               Prior episode of FN                  Sepsis syndrome

Invasive fungal infections or clinically documented infections

Treatment of Neutropenia

Is the patient experiencing severe chronic neutropenia?.................................................................................................

Yes

No

If yes:  Does the patient have any symptoms associated with severe chronic neutropenia (e.g., fever, infections, oropharyngeal ulcers)?..............................................................................................................

Yes

No

If yes:  Have diagnostic labs been evaluated (e.g., CBC with differential, platelet counts, bone marrow morphology and karyotype)?...............................................................................................................

Yes

No

Other: _______________________________________________________________________________________________________

Please provide supporting clinical documentation.

Continuation of Therapy (optional)

The above question set references the current medical policy: Colony Stimulating Factors (see Provider-Administered Drug Policies under “Resources” and “Policies and Guidelines” on the website on the back of the member’s ID card). After reviewing the medical policy, if the provider determines that the patient may not meet policy criteria AND the patient has been receiving treatment with the requested drug for a significant period of time, please complete the following questions for further consideration.

How long has the patient been receiving treatment with the requested agent?   ______________________________________________

Does the benefit of continued use with the requested agent outweigh the risk of adverse effects?..................................

Yes

No

If yes:  Please submit evidence (e.g. medical record documentation, supporting labs or tests) that the patient’s condition has stabilized or improved from baseline due to treatment with the requested agent, and evidence to support monitoring for adverse effects. Additional clinical/peer-reviewed literature supporting treatment is also welcome.

Is the patient at risk if treatment with the requested agent is discontinued?...........................................................................

Yes

No

Please fax or mail this form to:

Prime Therapeutics LLC

Medical Drug Review Department

2900 Ames Crossing Road

Eagan, MN 55121

CONFIDENTIALITY NOTICE: This communication is intended only for the use of the individual entity to which it is addressed. It may contain information that is privileged or confidential, including protected health information subject to HIPAA Privacy and Security Regulations. If you are not the intended recipient, dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone at 800.858.0723. Please do not destroy this fax until you have spoken with us. We may ask you to destroy or return the fax to us at our expense. Thank you for your cooperation.

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FAX: 877.239.9284    PHONE: 866.260.0452

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