Prior Authorization Request (Hematology Medication)

Document Title: Prior Authorization Request – Hematology Medication

Request Type: [Standard / Expedited-Urgent] (If Expedited-Urgent, include brief clinical justification for urgency below)

Urgency Justification: [Clinical rationale for expedited review] (Omit if Standard request)

Date Created: [Date] Requested Start Date: [Date]

Payer/Plan: [Payer name] Reference/Ticket Number: [Reference number if available]

Patient: [Full name] DOB: [Date] Member ID: [Member ID] Group ID: [Group ID if available]

Prescriber: [Name, credentials] NPI: [Number] Clinic: [Name, address, phone, fax] PA Contact: [Name, phone, fax or email for follow-up]

Diagnosis Code(s): [ICD-10-CM code(s)]

Drug Identifiers:

• Pharmacy benefit: [Drug name/strength/form], [Quantity], [Days' supply] (Include only if pharmacy benefit; omit if medical benefit)
• Medical benefit: [HCPCS J-code or Q-code], [NDC if required], [Site of care] (Include only if medical benefit; omit if pharmacy benefit)

Request Summary

• Requested Medication: [Generic name (Brand)], [formulation], [route], [dose], [frequency], [planned duration or renewal interval], [quantity and days' supply or number of cycles]
• Indication: [Disease name with subtype], [Line of therapy]
• Severity/Risk: [Stage, risk score, or cytogenetic risk category], [Reason time-sensitive if applicable]
• Eligibility Highlights:

  Test	Value	Units	Reference Range	Date	Source
  [Lab or biomarker]	[Value]	[Units]	[Ref range]	[Date]	[Internal / External]
  [Lab or biomarker]	[Value]	[Units]	[Ref range]	[Date]	[Internal / External]
  [Lab or biomarker]	[Value]	[Units]	[Ref range]	[Date]	[Internal / External]

  (Include only 3–6 decision-critical labs or biomarkers)
  • [Key pathology findings with date]
  • [Imaging or measurable disease summary with date] (Include only if relevant to eligibility or urgency)
• Prior Therapy Summary: [List of prior regimens with reasons stopped and dates]
• Guideline Support:
  • [Guideline or compendium name, version] – [Recommendation category]
• Monitoring Plan (Brief): [Baseline tests], [Monitoring cadence], [Key safety mitigations applicable to requested drug]

Diagnosis and Diagnostic Basis

Diagnosis: [Full disease name with subtype], initial diagnosis [Date], current status [newly diagnosed / relapsed / refractory / transformed / progressive / stable on therapy]

Diagnostic Evidence:

• Pathology: [Specimen type], [Date], [Key findings including morphology, blast percentage, immunophenotype as applicable]
• Cytogenetics/Molecular: [Test name], [Date], [Result and clinical significance] (List both positives and relevant negatives required by payer)
• Imaging: [Modality], [Date], [Measurable disease sites and dimensions] (Include only if relevant to indication)
• Non-malignant diagnostic criteria: [Required criteria elements such as factor levels, hemolysis pattern, platelet function] (Include only for non-malignant hematologic conditions)

Staging/Risk Stratification:

• System used: [Staging or risk classification system name]
• Assigned category: [Stage or risk category]
• Supporting inputs: [Values and findings with dates used to assign category] (If required score pending, state: Pending, ordered [Date])

Current Clinical Status

• Performance status: [ECOG or Karnofsky score], assessed [Date]
• Symptoms/signs linked to criteria: [B symptoms, bleeding, thrombosis, transfusion dependence, symptomatic anemia, or other documented findings with dates] (Include only objective or clearly documented findings)
• Complications: [TLS risk category, cytopenias, infections, organ involvement] with dates
• Related hospitalizations/ER visits: [Facility], [Date], [Reason and outcome] (Omit if none)
• Pregnancy/lactation status: [Status, last test date] (Include only if medication has reproductive risk)

Objective Data

(Include minimum data required to support eligibility, dosing, and safety for this drug)

Test	Value	Units	Reference Range	Date	Source
Hemoglobin	[Value]	g/dL	[Ref range]	[Date]	[Internal / External]
ANC	[Value]	×10⁹/L	[Ref range]	[Date]	[Internal / External]
Platelets	[Value]	×10⁹/L	[Ref range]	[Date]	[Internal / External]
Creatinine	[Value] (eGFR/CrCl: [Value])	mg/dL	[Ref range]	[Date]	[Internal / External]
AST	[Value]	U/L	[Ref range]	[Date]	[Internal / External]
ALT	[Value]	U/L	[Ref range]	[Date]	[Internal / External]
Total bilirubin	[Value]	mg/dL	[Ref range]	[Date]	[Internal / External]
[Disease-specific marker]	[Value]	[Units]	[Ref range]	[Date]	[Internal / External]

• Pathology/biomarkers: [Key positives and negatives with dates and report source]
• Imaging/measurable disease: [Modality], [Date], [Findings relevant to therapy choice or urgency] (Omit if not applicable)

Treatment History

Regimen/Drug	Line	Start Date	Stop Date	Best Response	Reason Stopped	Key Toxicity Details
[Regimen or drug]	[Line]	[Date]	[Date]	[CR / PR / SD / PD / NR]	[Progression / Intolerance / Contraindication]	[Toxicity details if intolerance]
[Supportive measure]	—	[Date]	[Date]	—	—	[Transfusions, G-CSF, antimicrobials]

(Use standard response terminology; include supportive measures only if payer requires)

Contraindications/Special Risks: [Drug–drug interactions preventing alternatives with rationale], [Organ dysfunction limiting choices with labs], [Prior serious adverse reactions]

Current Therapies: [Current regimen and intent], [Concomitant medications relevant to safety]

Coverage Criteria Crosswalk

Payer Criterion	Patient Evidence
[Diagnosis subtype confirmation]	[Pathology or molecular report, date, key result]
[Stage, risk, or biomarker requirement]	[Risk score or cytogenetic/molecular value with date]
[Line of therapy or prior regimen requirement]	[Number and names of prior therapies with stop reasons and dates]
[Baseline lab thresholds]	[Specific lab values and dates meeting thresholds]
[Concurrent therapy restrictions]	[Statement of compliance with dates and medication list]
[Age, pregnancy prevention, or site-of-care constraints]	[DOB, last pregnancy test, contraception plan, or site-of-care details as applicable]

(Map each payer requirement to explicit patient evidence; add or remove rows as needed)

Rationale

Guideline/Compendia Support:

• [Guideline or compendium name, version] – [Recommendation category]
• [If off-label: Coverage requested based on compendia support; brief evidence summary]

Patient-Specific Justification:

• [Why this drug fits patient's biomarkers, risk profile, organ function, comorbidities, or logistics]
• [Urgency or time-sensitive factors with dates] (Include only if applicable)

Why Alternatives Are Not Appropriate:

• [Previously failed options with objective progression or insufficient response and dates]
• [Contraindicated options with evidence or interactions]
• [Options with inferior efficacy or safety for this patient's profile]

Requested Medication Details

• Drug: [Generic name], [Brand if applicable], [formulation], [strength], [route]
• Dosing: [Dose], [frequency], [schedule], [cycle length if applicable]; [Fixed / weight-based / BSA-based]; Height [cm], Weight [kg], BSA [m²] (Include height/weight/BSA only if needed for dose calculation)
• Quantity: [Pharmacy: quantity and days' supply] or [Infusion: total mg per cycle]
• Duration: [Defined course or continue until progression/toxicity], [Reassessment interval]
• Dose Modifications: [Renal adjustment approach], [Hepatic adjustment approach], [Cytopenia hold/reduce criteria] (Cite reference source)
• Infusion regimen details: [Regimen name if combination], [Required premedications or hydration], [Site of care and required capabilities] (Include only for infusion drugs)

Monitoring and Safety Plan

• Baseline: [Required labs and timing], [Infection screening if applicable], [Pregnancy test and contraception plan if applicable], [Cardiac testing if applicable], [Vaccinations if immunosuppressive]
• On-Therapy Monitoring: [Labs and frequency], [Clinical assessments], [Response assessments and timing]
• Safety Mitigations: [TLS prophylaxis and monitoring plan], [Infection prophylaxis], [Growth factor and transfusion parameters], [Drug–drug interaction management] (Include only items applicable to requested drug)
• Stop/Hold Criteria: [Objective triggers for hold, reduce, or stop], [Escalation triggers], [Who will monitor and where]

Attachments Index

• ☐ [Recent labs: CBC, CMP, disease markers] – [Dates]
• ☐ [Pathology report(s)] – [Specimen and date]
• ☐ [Molecular/cytogenetic report(s)] – [Test and date]
• ☐ [Imaging report(s)] – [Modality and date]
• ☐ [Prior oncology/hematology notes documenting progression or intolerance] – [Dates]
• ☐ [Discharge summaries] – [Dates] (Include only if hospitalization supports severity)
• ☐ [Guideline excerpt or compendia citation] – [Version and date] (Include for off-label or uncommon indications)

(Attach only documents referenced in the crosswalk or rationale)

Provider Attestation

I attest that the above information is accurate to the best of my knowledge and that the requested therapy is medically necessary for the patient identified above.

Prescriber Signature: ____________________________ Date: [Date]

Peer-to-Peer Contact: [Name, direct phone] Best times for call: [Days and hours]

Please include specific reasons and any missing elements in the event of a denial to facilitate rapid resubmission.