Erythropoiesis-Stimulating Agents (Esas) Form - Blue Cross Blue Shield Of New Mexico Page 2
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1
2PREOPERATIVE
1. Scheduled for elective surgery __No __Yes, procedure(s)________________________________________________________________
__________________________________________________________________________________________________
2. Candidate for autologous blood transfusion __No __Yes
Explain ______________________________________________________________________________________________
__________________________________________________________________________________________________
3. At high risk for significant perioperative blood loss __No __Yes
Explain ______________________________________________________________________________________________
4. Document hemoglobin and hematocrit in Lab section above
Comments______________________________________________________________________________________________
____________________________________________________________________________________________________
PREMATURITY
1. Birth weight ___________________________________________Gestational Age________________________________________
2. Document hemoglobin and hematocrit in Lab section above
Comments ______________________________________________________________________________________________
HEPATITIS C
1. Medications – combination therapy:
Ribavirin______________________________________________ in combination with
Interferon alfa___________________________________________ OR Peg Interferon______________________________________
Other________________________________________________________________________________________________
2. Other causes of anemia are ruled out __Yes __No Explain ________________________________________________________________
__________________________________________________________________________________________________
3. Thyroid function normal __Yes __No
Treated (explain) _________________________________________________________________
__________________________________________________________________________________________________
4. Document hemoglobin and hematocrit in Lab section above
5. Hemoglobin <10 g/dL (document hemoglobin and hematocrit above) __Yes __No
(Or, Hemoglobin < 11 g/dL, with symptoms __________________________________________________________________________
__________________________________________________________________________________________________
6. Hypertension __No __Yes Treated(explain) _______________________________________________________________________
__________________________________________________________________________________________________
7. Ribavirin dose reduced by 200 mg/d from initial dose
__Yes, Response_______________________________________________________________________________________
____________________________________________________________________________________________
OR,
__No: evidence of cirrhosis __Yes __No
post-liver transplant __Yes __No
HIV Co-infection
__Yes __No
Comments______________________________________________________________________________________________
____________________________________________________________________________________________________
Additional Information________________________________________________________________________________________
____________________________________________________________________________________________________
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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