KAISER PERMANENTE REBLOZYL Prior Authorization User Guide

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

1. Is this request for initial or continuing therapy?
   □ Inial therapy
   □ Connuing therapy, State date: …………………………….

2. Indicate the Member’s diagnosis for the requested medication: …………………………….

3. Is the member ≥18 years of age? AND
   □ No □ Yes

4. Is the member diagnosed with beta thalassemia or hemoglobin E/beta thalassemia? AND
   □ No □ Yes

5. 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

6. 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:

1. 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

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