Catamaran Prior Authorization Department Phone: 877-228-7909 Fax: 866-511-2202 Caterpillar Prescription Drug Benefit Prescriber Information Last Name: First Name DEA/NPI: Specialty: Phone Fax - - - - Member Information Last Name: First Name Member ID Number DOB: - - Medication Information: Drug Name and Strength: Quantity and Dosing: __________________________________________________ _______________________________________________ Diagnosis: Duration: __________________________________________________ _______________________________________________ When advised below, please include all requested fax documentation (lab results, etc.) when submitting this Prior Authorization fax form; not submitting requested documentation could delay the clinical review process. Neupogen, Leukine Prior Authorization Form You must answer ALL of the following questions 1. Has the patient had a trial and failure of Granix? Please provide documentation. 2. Is the prescribed medication being used to prevent febrile neutropenia in a previously untreated adult or pediatric patient? 3. Does the patient have a diagnosis of non-myeloid malignancies and is receiving chemotherapy and/or radiotherapy with an expected incidence of febrile neutropenia of 20% or greater? 4. Is the patient at an increased risk for developing chemotherapy-induced infections due to any of the following reasons? (Please circle) 3 Pre-existing neutropenia (ANC of 1000/mm or more) Extensive prior exposure to chemotherapy Previous exposure of pelvis or other areas of large amounts of bone marrow to radiation History of recurrent febrile neutropenia from chemotherapy Patient is 65 years of age or older Patient has a condition that can potentially increase the risk of serious infection (i.e., HIV/AIDS) 5. Does the patient have any of the following conditions? Please submit documentation. 3 ANC of 1000/mm or more with BMT or myelodyplasia related neutropenia 3 ANC of 500/mm or more with HIV/AIDS 3 ANC of 1500/mm or more with severe chronic neutropenia of congenital, cyclic or idiopathic origin, or for use with peripheral blood progenitor cell (PBPC) transplantations Neutropenia due to acute leukemia (AML and ALL) 2 WBC count less than 3.0K/uL (3000 cells/mm ) and is post-transplantation of the liver or kidney Page 1 of 3 12/19/14 Y Y N N Y N Y N Y N Catamaran Prior Authorization Department Phone: 877-228-7909 Fax: 866-511-2202 Caterpillar Prescription Drug Benefit Granix Prior Authorization Form You must answer ALL of the following questions 1. Is the prescribed medication being used to prevent febrile neutropenia in a previously untreated adult or pediatric patient? 2. Does the patient have a diagnosis of non-myeloid malignancies and is receiving chemotherapy and/or radiotherapy with an expected incidence of febrile neutropenia of 20% or greater? 3. Is the patient at an increased risk for developing chemotherapy-induced infections due to any of the following reasons? (Please circle) 3 Pre-existing neutropenia (ANC of 1000/mm or more) Extensive prior exposure to chemotherapy Previous exposure of pelvis or other areas of large amounts of bone marrow to radiation History of recurrent febrile neutropenia from chemotherapy Patient is 65 years of age or older Patient has a condition that can potentially increase the risk of serious infection (i.e., HIV/AIDS) 4. Does the patient have any of the following conditions? Please submit documentation. 3 ANC of 1000/mm or more with BMT or myelodyplasia related neutropenia 3 ANC of 500/mm or more with HIV/AIDS 3 ANC of 1500/mm or more with severe chronic neutropenia of congenital, cyclic or idiopathic origin, or for use with peripheral blood progenitor cell (PBPC) transplantations Neutropenia due to acute leukemia (AML and ALL) 2 WBC count less than 3.0K/uL (3000 cells/mm ) and is post-transplantation of the liver or kidney Y N Y N Y N Y N Y Y N N Y N Y N Neulasta Prior Authorization Form You must answer ALL of the following questions 1. Does the patient weigh at least 45 kg or 99 lbs? 2. Is the prescribed medication being used to prevent febrile neutropenia in a previously untreated adult or pediatric patient? 3. Does the patient have a diagnosis of non-myeloid malignancies and is receiving chemotherapy and/or radiotherapy with an expected incidence of febrile neutropenia of 20% or greater? 4. Is the patient at an increased risk for developing chemotherapy-induced infections due to any of the following reasons? (Please circle) 3 Pre-existing neutropenia (ANC of 1000/mm or more) Extensive prior exposure to chemotherapy Previous exposure of pelvis or other areas of large amounts of bone marrow to radiation History of recurrent febrile neutropenia from chemotherapy Patient is 65 years of age or older Patient has a condition that can potentially increase the risk of serious infection (i.e., HIV/AIDS) Please note, not all drugs/diagnoses are covered on all plans. Comments: ________________________________________________________________________________________ Information given on this form is accurate as of this date. Caterpillar Prior Authorization forms are located at www.CatHealthBenefits.com on the “For Providers” tab. Print a new form for each request as forms are updated periodically. __________________________________________________________ Prescriber or Authorized Signature __________________________________________________________ Authorized Medical Staff – Name/Title Page 2 of 3 12/19/14 _________________________ Date Catamaran Prior Authorization Department Phone: 877-228-7909 Fax: 866-511-2202 Caterpillar Prescription Drug Benefit Attention Healthcare Provider: If you would like to discuss this request with a medical professional, please contact the Prior Authorization Department at 800-626-0072. I understand that Catamaran’s use or disclosure of individually identifiable health information, whether furnished by me or obtained by another source such as medical providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996). Page 3 of 3 12/19/14
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