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Aetna Precertification Notification 503 Sunport Lane Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 Erythropoietin Injectable Medication Precertification Request Aranesp®/Epogen®/Procrit® Please indicate: Start of treatment Continuation of therapy PATIENT INFORMATION First Name: Address: Home Phone: DOB: Height: Last Name: City: Work Phone: Allergies: Weight: State: Cell Phone: Dispensing Provider: Aetna Specialty Pharmacy® or Other: (Name) Phone: Fax: TIN: PIN: If Aetna Specialty Pharmacy is dispensing, Ship to: Patient’s home Doctor’s office ZIP: Other: PHYSICIAN INFORMATION First Name: Last Name: Address: Phone: Fax: Office Contact Name: Precertification Requested By: City: St. Lic. #: M.D./D.O. State: DEA #: Phone: Fax: NPI #: Phone: ZIP: UPIN: INSURANCE INFORMATION Primary Insurance: Member ID #: Secondary Insurance: Member ID #: Medicare: No Yes, provide ID #: Group #: Insured: Group #: Insured: Medicaid: No Yes, provide ID #: HISTORY & PHYSICIAL FINDINGS: Please indicate which of the following apply. Specific ICD-9 codes required where indicated by “*”. 042.0 Human immunodeficiency virus (HIV) 079.53 Human immunodeficiency virus, type 2 [HIV-2] 070.41 Hepatitis C acute or unspecified with hepatic coma 070.44 Chronic Hepatitis C with hepatic coma 070.51 Acute or unspecified Hepatitis C w/o mention of hepatic coma 070.54 Chronic Hepatitis C w/o mention of hepatic coma 070.70 Unspecified viral Hepatitis C w/o hepatic coma 070.71 Unspecified viral Hepatitis C with hepatic coma Is patient currently on Ribavirin? Yes No Is patient on chemotherapy? Yes No If Yes, date of last treatment: If No, is he/she scheduled for chemotherapy? If Yes, expected start date: LAB VALUES Anemia of chronic illness *Primary ICD-9: Chronic kidney disease (285.21 or 285.29) 8-week auth. (585.1-585.9) 16-week auth. 585.6 ESRD with dialysis 16-week auth. 776.6 Anemia of prematurity (Birth weight of grams, weeks) 6-week auth. gestational age of Patient scheduled to undergo high-risk surgery who is at increased risk of or intolerant to transfusions 8-week auth. Malignant neoplasm Yes Myelodysplastic syndrome No (140.0-204.91) 8-week auth. (238.72-238.75) 12-week auth. Other: PRESCRIPTION INFORMATION Aranesp Epogen Procrit Please note date of hemoglobin lab draw should be Please select medication: Please check appropriate code: within 2-4 weeks prior to request. Q4081 (ESRD); J0886 (ESRD); J0882 (ESRD) Hgb: g/dl: (mandatory) J0881 (non-ESRD); J0885 (non-ESRD) Date drawn: For HgB greater than 12 g/dl please indicate the Dosage Change: Ferritin: or % Saturation: From To or TIBC: and Serum Fe: Frequency Date of change Date of iron stores test: • Iron stores test is required for initial precert (must be drawn within past 12 months) • Is the patient receiving iron supplements? Yes No Dose/Route/Freq: Refills: For ESRD with dialysis and CKD: • Doses greater than 400,000U per month may not be approved. • If Hgb is >15g/dL, dose should be held until HgB ≤ g/dl; then restart at 50% less than previously administered dose. • If Hgb is >14 but ≤15g/dL, dose should be 25% less than previously administered dose. • If Hgb is >12 but ≤14g/dL, dose should be 10% less than previously administered dose. When initiating therapy (Carcinoma Dx only), if Hgb is between 10-12g/dL, please document any special clinical circumstances, including co-morbidities or symptoms, to support early initiation of therapy: Date: Prescriber’s signature (required by law if Aetna Specialty Pharmacy is the dispensing pharmacy): Interchange is mandated unless practitioner writes the words “NO SUBSTITUTION” in this space: GR-68425 (9-09)