FEP Aranesp Medical Review Request

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• Required *

• Enter Patient Information

• Drug Name: *
• Blue KC ID (Not SS#): *
  • i
  • i
  • i
• Patient First Name: *
• Patient Middle Initial:
• Patient Last Name: *
• Date of Birth: *
• Patient Group ID: *
• ICD-10 Diagnosis Codes: *

  Diagnosis Codes must be 3-8 characters along with decimals

  Codes must be 3 - 8 characters and 2 decimals.
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• Has the patient been using samples? Yes No
• Dose and Directions: *

• Required *

• Enter Provider Information

• Provider ID or NPI: *
• Provider's Name: *
• Physician's Specialty: *
• Street Address: *
• City: *
• State: *
• ZIP Code: *
• Email Address:
• Phone Number:
  Enter a 10 digit phone number.
• Fax Number:*
  Enter a 10 digit phone number.
• Contact First Name: *
• Contact Last Name: *
• Contact Email Address: *
• Contact Phone Number: *
• Contact Phone Ext:
• Contact Fax Number:*

• Anemia secondary to Chronic Renal Failure. *Note: Approval cannot be given unless all lab values are provided.
  1. What type of treatment regimen is being requested? *
     
     • Initial treatment
     • Continuation of treatment
  2. Is the patient on dialysis? *
     
     • Yes
     • No
  3. What is the patient's Hemoglobin? *
     g/dl
  4. What is the patient’s Serum Ferritin? *
     ng/ml
  5. If the patient is ON dialysis what action will be taken if the patient’s hemoglobin level is >10g/dl for initial treatment or >11g/dl for continuation of treatment?
     

     • Hold or reduce dose
     • Continue therapy despite FDA Boxed Warning
  6. If the patient is NOT ON dialysis what action will be taken if the patient’s hemoglobin level is >10g/dl for initial treatment >10g/dl for continuation of treatment?
     

     • Hold or reduce dose
     • Continue therapy despite FDA Boxed Warning
• Amemia secondary to chemotherapy
  1. Is patient receiving concomitant myelosuppresive therapy?
     
     • Yes
     • No
  2. Is the anticipated outcome of chemotherapy CURE of cancer?
     
     • Yes
     • No
  3. Is there a minimum of two additional months of planned chemotherapy?
     
     • Yes
     • No
  4. Will use of agent be discontinued upon completion of the chemotherapy?
     
     • Yes
     • No

If you have any additional information pertinent to this patient’s therapy, please specify.

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Revised 12/28/16