KAISER PERMANENTE REBLOZYL Prior Authorization User Guide
- June 15, 2024
- KAISER PERMANENTE
Table of Contents
User Guide
Kaiser Permanente Health Plan of Mid-Atlantic States, Inc.
REBLOZYL (Luspatercept) Prior Authorization (PA)
Pharmacy Benefits Prior Authorization Help Desk
Length of Authorizations: Initial- 6 months; Continuation- 6 months
Instructions:
This form is used by Kaiser Permanente and/or participating providers for
coverage of REBLOZYL (Luspatercept). Please complete all sections, incomplete
forms will delay processing. Fax this form back to Kaiser Permanente within 24
hours
fax: 1-866-331-2104. If you have any
questions or concerns, please call
1-866-331-2103. Requests will not be
considered unless all sections are complete.
KP-MAS Formulary can be found at:
http://www.providers.kaiserpermanente.org/mas/formulary.html
Patient Information
Patient Name:…………………………….
Kaiser Medical ID#:…………………………….
Date of Birth:…………………………….
Prescriber Information
Is the prescriber a Hematology-Oncology Specialist? □ No □ Yes
If consulted with a specialist, specialist name and specialty: …………………………….
Prescriber Name:…………………………….
Specialty:…………………………….
NPI:…………………………….
Prescriber Address:…………………………….
Prescriber Phone #:…………………………….
Prescriber Fax #:…………………………….
Pharmacy Information
Pharmacy Name:…………………………….
Pharmacy NPI:…………………………….
Pharmacy Phone #…………………………….
Pharmacy Fax #:…………………………….
Drug Therapy Requested
Drug 1: Name/Strength/Formulation: …………………………….
Sig:…………………………….
Drug 2: Name/Strength/Formulation:…………………………….
Sig:…………………………….
Diagnosis/Clinical Criteria
-
Is this request for initial or continuing therapy?
□ Inial therapy
□ Connuing therapy, State date: ……………………………. -
Indicate the Member’s diagnosis for the requested medication: …………………………….
-
Is the member ≥18 years of age? AND
□ No □ Yes -
Is the member diagnosed with beta thalassemia or hemoglobin E/beta thalassemia? AND
□ No □ Yes -
Is there documentation of receiving regular transfusions (defined as 6 or 20 RBC units in the 24 weeks prior to treatment initiation and no transfusion-free period for ≥35 days during that period)? AND
□ No □ Yes -
Is there documentation of the following?
a. Number of RBC transfusions within prior 6 months
b. Baseline hemoglobin
□ No □ Yes
For Continuation of Therapy, Please Respond to Additional Questions Below:
- Reassess every 6 months to determine need for continued therapy; therapy should be discontinued if the member meets any of the following criteria:
a. No clinically meaningful decrease in transfusions on maximum recommended dose
b. Non-adherence to the medication
□ No □ Yes
Prescriber Sign-Off
Additional Information – Please submit chart notes/medical records for the
patient that are applicable to this request.
Provide any additional supporting information that should be taken into
consideration:
I certify that the information provided is accurate. Supporting documentation
is available for State audits.
Prescriber Signature:…………………………….
Date:…………………………….
Please Note: This document contains confidential information, including
protected health information, intended for a specific individual and purpose.
The information is private and legally protected by law, including HIPAA. If
you are not the intended recipient, you are hereby notified that any
disclosure, copying, distribution or taking of any action in reliance on the
contents of this telecopied information is strictly prohibited. Please notify
sender if document was not intended for receipt by your facility
Kaiser Permanente Health Plan of Mid-Atlantic States, Inc.
Prior Authorization Form
Revision date: 3/4/2021