CurrentColorado Rocky Mountain Health PlansPolicy N/A

Erythropoeisis Stimulating Agents (Florida) Prior Authorization Form - Community Planopen_in_new

Prior authorization form for erythropoiesis-stimulating agents (ESAs) for Colorado Rocky Mountain Health Plans Community Plan (Florida). Collects patient, prescriber, medication selection, clinical history, labs, and required documentation for review; maximum approval length noted as 6 months.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyErythropoeisis Stimulating Agents (Florida) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and sign the PA form, attach official lab reports dated within 2 months and recent medical records, and fax to 1-866-940-7328 or call Pharmacy PA Call Center 1-800-310-6826.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

5Medications listed on form

6 monthsMaximum approval length

2Required max age of labs (months)

Policy overview

This is an administrative prior authorization (PA) form to request coverage and medical‑necessity review for erythropoiesis‑stimulating agents (ESAs) under Colorado Rocky Mountain Health Plans Community Plan (Florida). The form collects patient and prescriber demographics, medication selection and strength, directions, weight, and whether the request is for initiation or continuation of therapy, and requires the prescriber’s signature and date.

Clinical information collected includes medical history items (e.g., anemia due to renal failure with dialysis status and place of dialysis, anemia due to chemotherapy, hemolysis, antiretroviral therapy, folate/iron deficiency and current iron supplementation, GI bleed, perioperative transfusion risk, willingness to donate blood), current hemoglobin and hematocrit with lab dates, serum ferritin and transferrin saturation thresholds, and serum erythropoietin level with date. The form requires submission of official lab reports dated within 2 months and copies of medical records (diagnostic evaluations and recent chart notes) and related labs for review; providers must retain documentation for five years.

Submission and documentation requirements

Submission Requirements for PA Review

Form must be completed in full and accompanied by labs and medical records:

ALL of the following

Form completion: Form completed in full (patient and prescriber demographics, medication selection, strength, directions, weight, initiation vs continuation selection, prescriber signature and date)
Labs dated within 2 months: Official lab reports submitted and dated within 2 months of the PA
Medical records and recent labs: Copies of medical records (diagnostic evaluations and recent chart notes) and most recent related labs included
Documentation retention: Provider must retain copies of all documentation for five years

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Prior Authorization

Complete and submit PA form with labs and records

Complete the PA form in full, sign and date it, and attach official lab reports (must be dated within 2 months of the PA) plus copies of recent medical records and related labs. You may fax the completed form and attachments to 1-866-940-7328 or contact the Pharmacy PA Call Center at 1-800-310-6826 to submit.

Fax: 1-866-940-7328
Pharmacy PA Call Center: 1-800-310-6826

Documentation Required

Retain documentation

Providers must retain copies of all documentation submitted for PA review (including medical records and labs) for five years.

Clinical information collected on form

Required Clinical Information Collected

PA review requires documentation of the following clinical items (checkboxes on form):

ALL of the following

Diagnosis - renal failure: Diagnosis: anemia due to renal failure (acute or chronic) — dialysis status and place of dialysis documented if applicable
Diagnosis - chemotherapy: Diagnosis: anemia due to chemotherapy (yes/no)
Hemolysis: Is anemia due to hemolysis? (yes/no)
Antiretroviral therapy: Is anemia due to antiretroviral therapy? (yes/no)
Folate or iron deficiency: Is anemia due to folate or iron deficiency? (yes/no) — is patient currently receiving iron supplements? (yes/no)
GI bleed: Is anemia due to a GI bleed? (yes/no)
Perioperative transfusion risk: Is patient scheduled for elective, noncardiac, nonvascular surgery and at high risk for perioperative transfusions? (yes/no)
Willingness to donate blood? (yes/no)
Hemoglobin level (g/dL) with date of lab
Hematocrit (%) with date of lab
Serum Ferritin ≥ 100 ng/mL (Yes/No) with date>= 100 ng/mL
TSAT: Serum Transferrin Saturation ≥ 20% (Yes/No) with date>= 20%
Erythropoietin: Serum Erythropoietin Level (≤ 200 or > 200 to 500) with date≤ 200 or > 200 to 500

Lab thresholds

Serum Ferritin>= 100 ng/mL

Serum Transferrin Saturation>= 20%

Serum Erythropoietin Level<= 200 or > 200 to 500

Medication selection and approval length

Medication Selection and Approval Length

ANY of the following

Medication selection: Medication must be one of: Aranesp, Mircerna, Retacrit, Epogen, Procrit
Non-preferred list includes Mircerna, Procrit, Retacrit; check form for selection
Approval length: Maximum length of approval = 6 months6 months

No procedural or diagnosis codes provided on formmixed

No codes listed

Billing Rule

Approval duration

The maximum approval length for ESA therapy granted via this PA form is 6 months.

Background and purpose

Background: This PA form is used to request coverage of ESAs for Medicaid recipients under the Community Plan (Florida). It captures the medication choice (Aranesp, Mircerna, Retacrit, Epogen, Procrit) and whether the request is for initiation or continuation of therapy.

The form captures clinical indications and history needed for medical‑necessity review — including anemia due to renal failure (with acute vs chronic and dialysis details), anemia related to chemotherapy, hemolysis, antiretroviral therapy, folate or iron deficiency (and whether iron supplements are being given), GI bleeding, perioperative transfusion risk, and donor willingness — plus current hemoglobin, hematocrit, serum ferritin (threshold ≥ 100 ng/mL), transferrin saturation (threshold ≥ 20%), and serum erythropoietin category (≤ 200 or > 200 to 500) with lab dates.

Documentation requirements to support the PA review include official lab reports dated within 2 months of the PA and copies of medical records and recent chart notes; providers must retain copies of all documentation for five years. The form states the maximum length of approval = 6 months.