Fillable Clozapine Under 18 Years of Age Pharmacy Prior (Mercy Care)

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Clozapine Under 18 Years of Age Pharmacy Prior (Mercy Care)

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  • 46 check-boxes
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Country of origin: US
File type: PDF

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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
Clozapine Under 18 Years of Age
Pharmacy Prior Authorization Request Form
Do not copy for future use. Forms are updated frequently
REQUIRED: Office notes, labs and medical testing relevant to request showing medical justification are required to support diagnosis
Member Information
Member Name (first & last):
Date of Birth:
Gender:
Male
Female
Height:
Member ID:
State:
Weight:
Prescribing Provider Information
Provider Name (first & last):
NPI#
DEA#
Office Address:
State:
Zip Code:
Office Contact:
Office Phone
Office Fax:
Dispensing Pharmacy Information
Pharmacy Name:
Pharmacy Phone:
Pharmacy Fax:
Turn-Around Time
Standard – (24 hours)
Urgent – Waiting 24 hours for standard decision could seriously harm life, health, or ability to regain
maximum function; you are requesting an expedited decision.
Signature: _____________________________________________
______________
Requested Medication Information
Are there any contraindications to formulary medications?
Yes
(If yes, please specify):
No
New
request
Continuation
of therapy
For continuation of therapy
only:
There is improvement in psychosis
Yes
No
There was continued follow-up of labs per protocol
Yes
No
There is documentation of adherence and
tolerability
Yes
No
What medication(s) were tried and failed for this diagnosis?
Medication request is NOT for an FDA- approved, or compendia-
supported diagnosis (circle one):
Yes No
What is the diagnosis ICD-10 Code?
Diagnosis:
Directions for Use:
Quantity:
Day Supply:
Duration of Therapy/Use:
Strength:
Dosage Form:
Clinical Information
Does member have a clear diagnosis of schizophrenia or
schizoaffective disorder? Yes No
Was diagnosis determined after a detailed psychiatric evaluation by a child and
adolescent Behavioral Health Medical Provider?
Yes
No
Effective: 07/04/2019 C9870-A Page 1 of 2
Proprietary
click to sign
signature
click to edit
___________________________________________________
__________________
Is Behavioral Health Medical Provider enrolled in the REMS program?
Yes
No
Did evaluation include a full family, psychiatric and medical history?
Yes No
Did evaluation include a full medical and psychiatric review of
systems and complete MSE? Yes No
Yes
No
Is psychosis better accounted for by other diagnoses, including severe PTSD, substance induced psychosis,
bipolar disorder, neurologic condition, or hypnogogic hallucinations, and is persistent in absence of stressors?
Is the targeted treatment goal Yes No Was there a trial, and an inadequate response
for psychosis ONLY? with another formulary antipsychotic at the
maximum tolerated dose?
Yes
No
Did BHMP evaluate and determine
medication non-adherence was not reason
for inadequate response to maximum
tolerated dose?
Yes
No
Did BHMP rule out non-response due to
unrecognized or under-treated co-morbid
disorder?
Yes
No
Was an informed consent and youth assent
obtained prior to initiation?
Yes
No
N/
A
Were baseline labs completed
prior to start of medication?
Yes
No
If youth is inpatient, did an Acute or BHIF consultation with outpatient BHMP and CFT occur?
Yes
No
N/A
Was clozapine started during recent hospitalization?
Yes
No
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records.
Signature affirms that information given on this form is true and accurate and reflects office notes.
Prescribing Provider’s Signature: Date:
Please note: Incomplete forms or forms without the chart notes will be returned
Office notes, labs, and medical testing relevant to the request that show medical justification are required
Standard turnaround time is 24 hours. You can call 800-624-3879 to check the status of a request
Effective: 07/04/2019 C9870-A
Proprietary
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Clozapine Under 18 Years of Age Pharmacy Prior (Mercy Care)

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Completed 31 July 2021

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