Fillable Concomitant Antipsychotic Treatment Pharmacy Prior Authorization Request Form (Mercy Care)

Fill Online, Printable, Fillable, Blank Concomitant Antipsychotic Treatment Pharmacy Prior Authorization Request Form (Mercy Care) Form

Use Fill to complete blank online MERCY CARE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Concomitant Antipsychotic Treatment Pharmacy Prior Authorization Request Form (Mercy Care)

On average this form takes 16 minutes to complete

The Concomitant Antipsychotic Treatment Pharmacy Prior Authorization Request Form (Mercy Care) form is 2 pages long and contains:

  • 2 signatures
  • 49 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Mercy Care forms online.

BROWSE MERCY CARE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 2
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
Concomitant Antipsychotic Treatment
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:
City:
State:
Weight:
Prescribing Provider Information
Provider Name (first & last):
Specialty:
NPI#
DEA#
Office Address:
City:
State:
Zip Code:
Office Contact:
Office Phone
Dispensing Pharmacy Information
Pharmacy Name:
Pharmacy Phone:
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
aripiprazole
aripiprazole
aripiprazole
aripiprazole
aripiprazole
loxapine
loxapine
loxapine
loxapine
loxapine
perphenazine
perphenazine
perphenazine
perphenazine
perphenazine
Other (please specify):
Are there any contraindications to formulary medications?
Yes
(If yes, please specify):
No
New
request
Continuation
of
therapy
Medications were started during recent hospitalization (circle one):
Yes No
Medication request is NOT for an FDA approved, or compendia-
supported diagnosis (ci
rcle one):
Yes No
What is the diagnosis ICD-10 Code?
Diagnosis:
What medication(s) were tried and failed for this diagnosis?
Directions for Use:
Quantity:
Day Supply:
Duration of Therapy/Use:
Strength:
Dosage Form:
Clinical Information
Is the cross-tapering due to transitioning from one medication to another?
Yes
No
N/A
For refractory schizophrenia
Is there evidence of adequate trials with 3 individual antidepressants listed on the
Yes
No
Effective: 07/04/2019 C2962-A
Proprietary
_______________________________________________________
click to sign
signature
click to edit
spectrum disorder:
AHCCCS Behavioral Health Drug List, from 2 different therapeutic classes?
Were these trials for a period of 4-6 weeks at maximum tolerated doses?
Yes
No
Failures were due to ONE of the
following:
Inadequate response at maximum
tolerated doses
Adverse reaction(s)
Break through
symptoms
For refractory bipolar
disorder w/psychosis
and/or severe symptoms:
Were there trials of 4 evidence-
based treatment options
dependent upon episode type?
Yes
No
Were these trials for a
period of 4-6 weeks at
maximum tolerated doses?
Yes
No
Failures were due to ONE of the following:
Inadequate response at
maximum tolerated doses
Adverse reaction(s)
Break through symptoms
Are there TWO different prescribers prescribing that the coordination of care has occurred?
Yes
No
Is there documentation that adherence to treatment regimen was not a contributing factor to inadequate response to
medication trials?
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 m
edical 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
Effect
ive: 07/04/2019 C2962-A
Proprietary
Page 2 of 2
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Concomitant Antipsychotic Treatment Pharmacy Prior Authorization Request Form (Mercy Care)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 31 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document