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FEP Aranesp Medical Review Request

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* Required Field

Enter Patient Information

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

* Required Field

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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Or, print the form and mail to:

Blue Cross and Blue Shield of Kansas City
Pharmacy Services
P.O. Box 412735
Kansas City, MO 64141-2735

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Revised 12/28/16

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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