Effective: 08/18/2020 C4592-A Page 1 of 3
Fax completed prior authorization request form to 800-854-7614 or submit Electronic Prior Authorization through
CoverMyMeds® or SureScripts.
All requested data must be provided. Incomplete forms or forms without the chart notes will be returned
Pharmacy Coverage Guidelines are available at
www.mercycareaz.org/providers/completecare-forproviders/pharmacy
Colony Stimulating Factors (CSF)
Pharmacy Prior Authorization Request Form
Do not copy for future use. Forms are updated frequently.
REQUIRED: Medical records, including labs and weight or body surface area (BSA), to support diagnosis are required to be submitted
Member Information
Member Name (first & last): Date of Birth: Gender:
☐ ☐ Male Female
Height:
Member ID: City: State: Weight:
Prescribing Provider Information
Provider Name (first & last): Specialty: NPI# DEA#
Office Address: City: State: Zip Code:
Office Contact: Office Phone Office Fax:
Dispensing Pharmacy Information
Pharmacy Name: Pharmacy Phone: Pharmacy Fax:
Requested Medication Information
Preferred Short Acting: Neupogen Disposable Syringe Neupogen Vial
Preferred Long Acting:
Fulphila Udenyca
Non-Preferred Short-Acting: Granix Leukine Nivestym Zarxio
Non-Preferred Long-Acting: Neulasta Neulasta Onpro
Ziextenzo
Other, please specify:
Are there any contraindications to formulary medications?
Yes No
If yes, please specify:
New
request
Continuation of
therapy request
For continuation of therapy
requests ONLY:
Response to therapy Recent ANC, CBC and/or
PLT counts
Chemotherapy induced neutropenia ONLY:
Recent ANC showing response to therapy
Directions for Use: Strength: Dosage Form:
Quantity: Day Supply: Duration of Therapy/Use:
What medication(s) has member tried and failed for this diagnosis? Please specify:
Medication request is NOT for an FDA approved, or compendia-
supported diagnosis (circle one): Yes No
Diagnosis: ICD-10 Code:
Turn-Around Time for Review
Standard – (24 hours) Urgent – waiting 24 hours for a standard decision could seriously harm life, health, or
ability to regain maximum function, you can ask for an expedited decision.
Signature:
_______________________________________________________
Clinical Information
Will requested medication be used concomitantly with radiation AND chemotherapy? Yes No
Will requested medication be administered
at appropriate time after chemotherapy OR
radiation?
Yes No Will requested medication be used in
combination with other myeloid growth factors?
Yes No
Chemotherapy-Induced Febrile Neutropenia
PRIMARY Prophylaxis
Member is receiving chemotherapy for NON-myeloid cancer AND Chemotherapy regimen is given after bone marrow transplant
click to sign
signature
click to edit