CurrentAnthemPolicy N/A

Prior Authorization Form: Non-Preferred Colony Stimulating Factors

This form governs prior authorization requests for non-preferred colony stimulating factor (CSF) agents for Anthem HealthKeepers Plus Medicaid members in North Carolina and describes required member, prescriber, diagnosis, and documentation information for initial and renewal requests.

Policy Summary

PayerAnthem

PolicyPrior Authorization Form: Non-Preferred Colony Stimulating Factors

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionConfirm member meets FDA labeling or provide compendia-supported rationale and attach supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form per member required

FDA & compendiasupports required for medical necessity

844-512-7020submission fax number

requiredprescriber signature required

Coverage Criteria for Non-Preferred CSFs

inv-01: Initial Therapy

Initial request is reviewed when ALL of the following are addressed on the form:

Initial CSF request: Provider must indicate whether member age is within FDA labeling for the requested indication OR provide supporting information if not; provide clinical evidence from accepted compendia (DrugDex level 1, 2a, or 2b; or NCCN level 1, 2a, or 2b).

Attach supporting documentation as indicated on the form.

inv-02: Continuation Therapy

Renewal requests are reviewed when ALL of the following are affirmed:

Renewal criteria: Member continues to meet the initial criteria; member has an absence of unacceptable toxicity to the drug; member is being appropriately monitored for a beneficial response to therapy.

Each item must be answered Yes on the renewal section.

Policy Summary

PayerAnthem

PolicyPrior Authorization Form: Non-Preferred Colony Stimulating Factors

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionConfirm member meets FDA labeling or provide compendia-supported rationale and attach supporting clinical documentation.

SourceLink

On This Page

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Prescriber and Submission Requirements

Prior Authorization

Prior Authorization Required

Initial and renewal prior authorization requests must confirm the member meets FDA labeling for age for the requested indication or provide a supporting rationale for off-label use. Include complete administrative and drug details and attach clinical evidence that supports medical necessity when use is based on compendia.

Complete member demographics: last name, first name, Medicaid ID number, date of birth, expected pregnancy term date (if applicable), weight in kilograms, requested start date.
Provide prescriber details: last name, first name, NPI number, phone number, fax number, and prescriber signature with date.
Provide detailed drug information: drug name/formulation, strength, dosing frequency, length of therapy, quantity per day.
For initial requests: Indicate whether the member's age falls within FDA labeling for the requested agent and indication. If not within labeling, provide documentation and clinical rationale supporting use for the member's age.
Medical necessity documentation: Attach clinical evidence supporting the requested use when based on compendia. Acceptable compendia/evidence levels: DrugDex level 1, 2a, or 2b; or NCCN category 1, 2a, or 2b recommended use. Attach supporting documentation.
For renewal requests: Confirm the member continues to meet initial criteria, has no unacceptable toxicity to the drug, and is being appropriately monitored for benefit.
Incomplete forms or missing requested information can delay the prior authorization process. Submission of documentation does not guarantee coverage. Fax completed form to 844-512-7020.

Background

Colony stimulating factors (CSFs) are hematopoietic growth factors used to stimulate production of blood cells and are commonly prescribed for management of chemotherapy‑induced neutropenia and other hematologic indications. This prior authorization form is used to document that use of a non‑preferred CSF meets medical necessity by confirming FDA‑labeling applicability for the member’s age or providing supporting rationale when the request is for an off‑label age, and by requesting compendia‑level clinical evidence to justify therapy.

To support an initial approval the provider must indicate whether the member’s age falls within the FDA‑labeled indication for the requested agent or provide supporting information if not, and attach clinical evidence from accepted compendia (DrugDex or NCCN at levels 1, 2a, or 2b). For renewals the form requires confirmation that the member continues to meet initial criteria, has an absence of unacceptable toxicity, and is being appropriately monitored for benefit.

OpenPayer

Prior Authorization Form: Non-Preferred Colony Stimulating Factors

Coverage Criteria for Non-Preferred CSFs

Initial Authorization Criteria

Continuation / Renewal Criteria

Prescriber and Submission Requirements

Background

Compendia and Evidence Definitions