01/04/2012 <%PANumber%>
MEDIGOLD (MEDICARE) 1307
Aranesp (Medicare Determination)

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Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-866-239-8303.
Please contact CVS/Caremark at 1-800-294-5979 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of Aranesp (Medicare Determination).
Drug Name (select from list of drugs shown)
Aranesp (darbepoetin alfa)
Patient Information
Patient Name:    
Patient ID:    
Patient Group No.:    
Patient DOB:    
Prescribing Physician
Physician Name:    
Physician Phone:    
Physician Fax:    
Physician Address:    
City, State, Zip:    
Diagnosis:     ICD Code:  
Please circle the appropriate answer for each question.
  1. Does the prescriber (i.e., nephrologist, nurse practitioner, or physician assistant) receive a monthly capitation payment to manage end-stage renal disease (ESRD) care for this patient?
    Y   N    
   [If no, skip to question 3; the drug is not ESRD-related.]
  2. Is the drug prescribed to be used for an ESRD-related condition?
    Y   N    
   [If yes, no further questions; the drug is ESRD-related and not covered under Part D.]
  3. Is therapy furnished “incident to” physician services (i.e., drug is purchased by the physician and then administered by the physician or under the physician’s direct supervision)?
    Y   N    
  4. Is the patient’s blood pressure under control and has the prescriber advised the patient (or caregiver) to report significant signs or symptoms of cardiovascular and thrombotic events?
    Y   N    
   [If no, then no further questions.]
  5. Has the patient received 12 weeks of therapy with Aranesp?
    Y   N    
   [If no, skip to question 11.]
  6. Is renewal of therapy requested for a patient with myelodysplastic syndrome (MDS)?
    Y   N    
   [If yes, then skip to question 9.]
  7. Is renewal of therapy requested for a patient with one of the following diagnoses?
    Y   N    
   Chronic kidney disease, OR / Non-myeloid, non-curative metastatic malignancy with anemia due to chemotherapy
   [If no, then no further questions.]
  8. Does the patient have adequate iron stores (TSAT greater than or equal to 20%, serum ferritin greater than or equal to 100ng/mL) OR is the patient receiving concomitant iron supplementation?
    Y   N    
   [If no, then no further questions.]
  9. Has hemoglobin increased greater than or equal to 1g/dL in response to Aranesp?
    Y   N    
   [If no, then no further questions.]
  10. Does the patient meet one of the following criteria regarding the current hemoglobin level?
    Y   N    
   Hemoglobin is below 12 g/dL, OR / Hemoglobin is less than 13 g/dL and the Aranesp dose has been reduced
   [No further questions.]
  11. Does the patient have a diagnosis of non-del(5q) MDS?
    Y   N    
   [If no, then skip to question 13.]
  12. Does the patient meet both PRETREATMENT criteria for use in MDS?
    Y   N    
   Serum erythropoietin level less than or equal to 500 mU/mL, AND / Hemoglobin less than 10 g/dL or 10-11 g/dL with clinical symptoms of anemia
   [No further questions.]
  13. Does the patient have chronic kidney disease?
    Y   N    
   [If yes, then skip to question 16.]
  14. Does the patient have a non-myeloid, non-curative metastatic malignancy?
    Y   N    
   [If no, then no further questions.]
  15. Is the anemia due to concomitant myelosuppressive chemotherapy?
    Y   N    
   [If no, then no further questions.]
  16. Does the patient have a PRETREATMENT hemoglobin less than 10 g/dL or 10-11 g/dL with clinical symptoms of anemia?
    Y   N    
   [If no, then no further questions.]
  17. Does the patient have adequate iron stores (TSAT greater than or equal to 20%, serum ferritin greater than or equal to 100ng/mL) OR is the patient receiving concomitant iron supplementation?
    Y   N    

Comments:  

I affirm that the information given on this form is true and accurate as of this date.

 
Prescriber (Or Authorized) Signature and Date