Erythropoiesis-Stimulating Agents (Esas) Form - Blue Cross Blue Shield Of New Mexico

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Erythropoiesis-Stimulating Agents (ESAs)
Erythropoiesis-Stimulating Agents, including Epoetin alpha (Epogen
, Procrit
, and Darbepoeitin (Aranesp
)
®
®
®
Medical Policy – RX501.069
Please complete all appropriate questions fully.
Suggested medical record documentation:
Current History & Physical
Progress Notes
Lab Reports
•
•
•
*Failure to include suggested medical record documentation may result in delay or possible denial of request.
PAT I E N T I NF OR M ATI O N
Name:
Member ID
P R O C E DU RE I NF O RM AT I ON
Primary Diagnosis _____________________________________________________________________ Date _________________
Secondary Diagnoses ___________________________________________________________________ Date _________________
___________________________________________________________________ Date _________________
___________________________________________________________________ Date _________________
Date of initiation of therapy ____________________________________________________________________________________
(When possible, please give at least 24 hours notice)
c J0885 (Procrit
, Epogen
)
c J0886 (Procrit
, Epogen
)
®
®
®
®
Requesting authorization for:
c Q4081 (Procrit
, Epogen
)
®
®
c J0881 (Aranesp
)
c J0882 (Aranesp
)
®
®
LAB VALUES Please note: If therapy has already been initiated, we must receive values from PRIOR to administration
Hemoglobin (HGB)
Hematocrit (HCT)
Blood Ferritin Level
Date __________ Value _________ Date __________ Value _________ Date__________ Value_________
Date __________ Value _________ Date __________ Value _________ Date__________ Value_________
Date __________ Value _________ Date __________ Value _________ Date__________ Value_________
Transferrin Saturation
Date___________ Value_________ Date__________ Value _________ Date__________ Value_________
CHEMOTHERAPY
1. Date chemotherapy initiated ___________________________________________________________________________________
2. Expected duration of chemotherapy _______________________________________________________________________________
3. Chemotherapy agent(s) administered ______________________________________________________________________________
4. Cause of anemia _________________________________________________________________________________________
5. Anticipated outcome of chemotherapy _____Cure
_____Palliative
Comments ______________________________________________________________________________________________
____________________________________________________________________________________________________
HIV
1. AZT (zidovudine) administration _________________________________________________________________________________
2. Endogenous serum erythropoietin level _____________________________________________________________________________
Comments ______________________________________________________________________________________________
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
81927.0811

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