Prior Authorization Procrit/aranesp Form-Children'S Medical Services Network
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CHILDREN’S MEDICAL SERVICES NETWORK
Prior Authorization
®
®
Procrit
/Aranesp
(Note: Maximum Length of Approval is 6 Months)
Note: Form must be completed in full. An incomplete form
may be returned.
Recipient’s Medicaid ID#
Date of Birth (MM/DD/YYYY)
/
/
Recipient’s Full Name
Prescriber’s Full Name
Prescriber License # (ME, OS, ARNP, PA)
Prescriber Phone Number
Prescriber Fax Number
-
-
-
-
MEDICATION
STRENGTH
DIRECTIONS
Procrit
Aranesp
___________________
___________________________________________________________________________________
Weight: ___________ lbs or ___________ kgs as of _____________ (date)
INITIATION OF THERAPY
-OR-
CONTINUATION OF THERAPY
MEDICAL HISTORY
Yes
No
Acute
Chronic
Anemia due to renal failure?
If yes, please complete the following:
Yes
No
Home
Dialysis Center
Dialysis?
Place dialysis received:
Yes
No
Yes
No
Anemia due to chemotherapy
Is anemia due to hemolysis?
Yes
No
Yes
No
Anemia due to antiretroviral therapy?
Is anemia due to folate or iron deficiency?
Is patient currently receiving iron
Is anemia due to a GI bleed?
Yes
No
Yes
No
supplements?
Yes
No
Is patient scheduled to undergo elective, noncardiac, or nonvascular surgery and at high risk for perioperative transfusions?
Yes
No
Willing to donate blood?
NOTE: OFFICIAL LAB REPORTS MUST BE SUBMITTED AND DATED WITHIN TWO MONTHS OF THE PRIOR AUTHORIZATION
REQUEST. FORM AND LAB DATA MUST BE COMPLETED IN FULL.
Hemoglobin Level (g/dL): ________________________
Hematocrit (%): ______________________________
Date of lab: __________________________________
Date of lab: ____________________________________
Serum Ferritin ≥ 100 ng/mL :
Serum Tranferrin Saturation ≥ 20% :
Yes
No
Yes
No
Date of lab: ____________________________________
Date of lab: ___________________________________
≤ 200
Serum Erythropoietin Level:
>200 to 500
Date of lab: ______________________________
Prescriber’s Signature: __________________________________________ Date: ____________________________
REQUIRED FOR REVIEW: Copies of medical records (i.e., diagnostic evaluations and recent chart notes), a copy of the original
prescription, and the most recent copies of related labs.
The provider must retain copies of all documentation for five years.
Fax or mail completed forms to:
Magellan Rx Management
Prior Authorization
P. O. Box 7082
Tallahassee, FL 32314-7082
Phone: (877) 553-7481
Fax: (800) 424-5716
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